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For all municipal business license questions, contact City of South Bend • Department of Community Investment <br />227 Wes:Jefferson Blvd • Suite 14005 'South Bend, Indiana 46603 • 574.235.5912 • F: 574.235.91321 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Business Address: <br />City: .State: Zip: <br />Residential Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: o S <br />B. Residential Address: <br />City: M.a, Aw aks State: IN Zip: N(o S4S <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number:61LI - 850 -31Qci <br />F. E-Mail Address: mv%j{n ,c4sapigl'6 AP3jAI.Feaara <br />G. Position with business: 0t a.ar ( CEO <br />H. Please list all criminal convictions (if any), excluding trafficviolations: <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 applicationdate: <br />Street Address City State Dates <br />c103 "1 X\y Or ST; IN 67/2.0t g - lo/� <br />