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1 <br />For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 <br /> <br /> <br /> <br /> <br />LICENSE APPLICATION FOR - MASSAGE THERAPIST <br />MUNICIPAL CODE SECTION - 4-35 <br /> <br />I. APPLICATION TYPE Check One: New Renewal <br /> <br />II. PERSONAL DATA <br />A. Applicant's Legal Name: <br />B. Residential Address: <br />City: State: Zip: <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />F. E-Mail Address: <br />G. Please list all residential addresses for three (3) years immediately prior to application date: <br />Street Address City State Dates <br /> <br /> <br /> <br />(Attach additional sheets if necessary) <br />H. Date of birth: <br />I. Gender: <br />J. Social Security Number: <br />K. Race: <br /> <br /> <br /> <br /> <br />For Office Use Only <br /> <br />Application Filed Health Dept. Approval <br />Application Fee Paid Police Dept. Approval <br />Sent to Dept. License Fee Paid <br />License Number <br /> <br />Not Approved <br />Reason