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2 <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 />LICENSE APPLICATION FOR - PEDDLERS AND CANVASSERS <br />MUNICIPAL CODE SECTION - 4-43 <br /> <br />III. PERSONAL DATA <br />A. Applicant's Legal Name: <br />B. Residential Address: <br />City: State: Zip: <br />C. Residential Telephone Number: <br />D. Cellphone Number: <br />E. E-Mail Address: <br />F. Position with Business: <br />G. Social Security Number: H. Gender: <br />I. Date of Birth: J. Race: <br />K. Honorably discharged veteran: Yes No <br />If yes, please attach a copy of your DD214 papers. <br />L. Convictions of Felony: Yes No Police Record: Yes No <br />M. Convictions of any misdemeanors or violations of any city ordinance: Yes No <br />N. If yes to any of the above, describe the nature of offense(s) and punishment or penalty <br />assessed (other than for traffic moving violations). <br /> <br /> <br />IV. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br /> <br />V. INCLUDE A COPY OF A STATE ISSUED ID OR DRIVER’S LICENSE <br /> <br />VI. AFFIRMATION <br /> <br />I, hereby, certify and affirm that all of the information I have given in this application is true and <br />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 have read and understand <br />the regulations of the Peddlers and Canvassers license found in the City of South Bend Municipal <br />Code, Section 4-43. <br /> <br /> <br /> <br /> <br />Signature Date