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For all municipal business (trine questions, mntac : City of South Bend • Department of Community Investment <br />227Wertlefferaon Blvd -Suite 140 S•South Bend, Indiana 46601• 574.235.5912• F. 574.235.9021 <br />LICENSE APPLICATION FOR -TRANSIENT MERCHANT <br />MUNICIPAL CODE SECTION - 4.60 <br />V. PERSONAL DATA (Additional Owner, if applicable) <br />A. Owner's Legal Name: <br />B. Residential Address: <br />City: State: Zip: <br />C. Residential Telephone Number: <br />D. Celephone Number: <br />E. Position with business: <br />F. Social Security Number. <br />G. Gender: <br />H. Date of birth: <br />I. Race: <br />VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />VII. INCLUDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL GROUP EVENTPARTICIPANTS. <br />VIIl. INCLUDE A CURRENT CERTIFICATE OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND LISTED <br />AS THE CERTIFICATE HOLDER. <br />I%. AFFIRMATION <br />I, hereby, certify and affirm that all of the Information I have given in this application is true and <br />accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. I understand that the <br />completed application must be filed no later than thirty days before the planned event is to <br />begin. I have read and understand the regulations of the Transient Merchant license found in <br />the City of South Bend Municipal Code, Section 4-60. <br />8/1/25 <br />Signature Date <br />3 <br />