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Jan 11 2017 16:30:05 Via Fax -> Vonage Page 007 0f 007 <br />For all municipal business license questions, contact: City of South Rend + ISegartment of C'oMalkinillY mvestmemt <br />2,V WestUefferscnl Blvd * Suite 1400 S -South Send, Indiana 46601 e S74.215.5912 • F: 574.2M ,9021 <br />I..ICENSE APPLICATION FOR --TRA.NSIENT MERCHANT <br />MUNICIPAL CODE SECTION - 4-60 <br />City:_ East Leroy _State:,_ _ .,MI —Zip: 49051 <br />C. Residential Telephone Number: 264 9�9,9860 .-__ ......_. <br />D. Cellphone Number: <br />E. Position with business:___ President ...... <br />F. Social Security Number: Please all andj wiiY i its@vr„de. <br />G. Gender: _F_.._ <br />H. Date of birth: _ z f 17l46 <br />1. Race:, ,,._,__CaucaSian <br />VI_ INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />VII. INCLUDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL GROUP EVENT PARTICIPANTS. <br />Vlll. INCLUDE. A CURRENT CERTIFICATE OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND LISTED <br />AS THE CERTIFICATE HOLDER. <br />IX. AFFIRMATION <br />1, 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 kaeforce the planned event is to <br />begin. I have read and understand- 'e regulationx of the Transient Merchant license'found in <br />the City of South nd ML . ., ode, Section 4-60. <br />Signature <br />1 _ <br />Date <br />