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For all municipal business license questions, contact: C'4v of south Bend • Department oFCommun'4v Investment <br />222 aren Jefferson Blvd • Suite 14m9 •South Bend, Indiana 46601 •57C2355912 • F:574.235.9011 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name#3: So FIOWEK a A LETitle: <br />Business Address: 4'2� �m I'�[C-0ril %Aa <br />City: State: Zip: <br />Residentl IAdress�:( 7)q�wk l �i� <br />City:�Yk�Hi State: Zip' <br />IV. PERSONAL DATA '7e <br />A. Applicant's Legal Name: 7 III <br />B. Residential Alllddrerss 11��-- <br />City�1111Ch/l1AilAK/A State: Zip:_ <br />C. Residential Telephone Number: <br />D. Residential Fax Numbe <br />E. Cellphone Number: <br />.�,rr77 <br />F.E-Mail Address: iIA <br />G. Position with business: <br />H. Please list all criminal convictions (if any), excluding traffcviolations: <br />Nature of Conviction City State Date <br />(Attach additional sheets if necessary) <br />I. Please list all addresses for three (3) years prior to application date: <br />Street Address City State Dates <br />411 Wiri f kA4-kiL IQU{ 13Ak 6y_ 1013 10 <br />Attach additional sheets "f necessa y) <br />