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For all mundpal business license questions, wni City of South Bend • DeBanment of Community Investment <br />227 West Jefferson BIW • Suite terns •5ouM Bend, Indiana 46601 • 5]4.2355M • F:574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />III.OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Title: <br />Business Address: <br />City: State: <br />Zip: <br />Residential Address: <br />City: State: <br />Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal No OUt He <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: kf YDSf_ SD0._ I�rycf (, CO(A <br />G. Position with business: <br />H. Please list all criminal convictions if arty), excluding trafficviolations: <br />Nature of Conviction <br />Conviction City State <br />Date <br />IV <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 <br />Dates <br />(Attach additional sl <br />J. Date of birth <br />K. Gender: <br />L. Social Security Number. <br />M. Race: <br />3 <br />