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For all municipal business license questions,contact:City of South Bend•Department of Community Investment <br /> 215 S.Dr.Martin Luther King Jr.Blvd.•Suite 500 <br /> South Bend,Indiana 46601 S74.235.5912•F:574.235.9021 <br /> LICENSE APPLICATION FOR-SCRAP METAL DEALERS/JUNK DEALERS/RECYCLING <br /> OPERATIONS <br /> CITY OF SOUTH BEND, INDIANA <br /> MUNICIPAL CODE SECTION-4-51 <br /> III.PERSONAL DATA ,^n <br /> A.Applicant's Legal Name: <br /> B. Residential Address: <br /> City: <br /> C. Residential Telephone • _ <br /> D.Celephone Number: <br /> E.Social Security <br /> G. Date of Birth: <br /> I. Position with Business <br /> IV.INCLUDE,WITH APPLICATION,A SITE PLAN OF THE FACILITY SHOWING PROPERTY LINES,BUILDINGS, <br /> PARKING SPACES,LOADING DOCKS,FUEL STORAGE,AND LANDSCAPING. <br /> V.INCLUDE$5.00 PROCESSING FEE WITH APPLICATION <br /> VI. INCLUDE A COPY OF THE INDIANA SECRETARY OF STATE CERTIFICATE OF ORGANIZATION <br /> CONFIRMING THAT THE BUSINESS IS REGISTERED AND IS DULY QUALIFIED TO DO BUSINESS IN THE <br /> STATE OF INDIANA. <br /> VII. LICENSEE MUST COMPLY WITH ALL LOCAL.AND STATE REGULATIONS REGARDING SCRAP METAL <br /> DEALERS,INCLUDING THOSE REALTED TO RECORD KEEPING,IDENTIFICATION,AND REPORTING. <br /> VIII.AFFIRMATION <br /> I,hereby,certify and affirm that all the information f have given in this application is true and <br /> accurate to the best of my knowledge. I further certify and affirm that I have in no way <br /> attempted to mislead the City in this application by omitting facts known to me. I have read and <br /> understand the regulations of the Scrap Metal Dealer/Junk Dealer/Recycling Operation/Transfer <br /> Station license found in the City of South Bend Municipal Code,Section 4-51. <br /> )f <br /> Signature Date <br /> 2 <br />