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For all municipal business license questions, contact City of South Bend • Ce parlment a Community Investment <br />222 West Jefferson Blvd • Suite 1400 5 -South Bend, Indiana 46501. 524.2355912 • F: 574.235.9021 <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_ Zips <br />Residential Address: <br />City; State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Nan <br />B. Residential Address <br />City: Sta ": ��� Zip: <br />C. Residential Telephone NumberA l /� 1 I� <br />D. Residential Fax Numb r: 11 <br />E. Cellphone Number <br />F. E-Mail Address: <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 />r <br />(Attach additional sh is if.ne essary) <br />1. <br />L <br />3 <br />