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For munidpal bus real license question¢, contact City of South Bend • Department of community Invenment <br />227 weRBefferwn But! • Suite 14005 -South Bend, Indiana 46601 •574.235.5912 • R S74.2SS'9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />Ill. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name#3: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Na Jin Wang <br />B. Residential Addre�e <br />city SrarON Zip: <br />C. Residential Telephone Number: 574-888-3888 <br />D. Residential Fax Number: <br />E. Cellphone Number: 574-888-3868 <br />F. E-Mail Address: jingwang0329@gmaii.com <br />G. Position with business: Owner <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 forthree (3) years prior to application date: <br />Street Address City State Dates <br />4240 Irish Hills South Bend IN 9-2021 to9-202 <br />(Attach additional sheets if necessa <br />1 <br />