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3 <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 />LICENSE APPLICATION FOR - MASSAGE THERAPIST <br />MUNICIPAL CODE SECTION - 4-35 <br />III.BUSINESS DATA <br />A.Do you intend to be employed with a Massage Establishment: Yes No <br />If yes, name and address of establishment: <br />B.Have you ever had a Massage Therapist license, or similar license, suspended or revoked by <br />any governing municipality within three (3) years prior to the date of this application: <br />YES NO <br />1.If yes, what was the reason? <br />2.If yes, what was the business occupation following the suspension/revocation: <br />IV.INCLUDE WITH APPLICATION: <br />•Copy of driver’s license or government issued identification. <br />•Copy of Indiana Professional License approved by the State Board of Massage Therapy. <br />•A diploma or certificate of graduation from a recognized school of massage. <br />•Three (3) passport photos taken within 6 months of application. <br />•St. Joseph County Massage Therapist Permit <br />V.INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />VI.AFFIRMATION <br />I, hereby, certify and affirm that all of the information I have given in this application is true <br />and accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. I agree to cooperate with <br />the City in the investigation of this application. I have read and understand the regulations of <br />the Massage Establishment and/or Therapist license found in the City of South Bend Municipal <br />Code, Section 4-35. <br />Signature Date