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For all municipal business license questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574,235,9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />III. OWNERSHIP <br />A. Type of ownership (check one): <br />Sole Proprietorship. (If sole proprietorship, proceed to 1). <br />Partnership (If partnership, proceed to 2). <br />'>c Corporation (If corporation, proceed to 3). <br />1. Sole Proprietor <br />Name: <br />Residential Address: <br />City: State: <br />2. Partnership (List at least two (2) partners) <br />Name #1: <br />Residential Address: <br />City: <br />Name #2: <br />Residential Address: <br />City: <br />Zip: <br />State: Zip: <br />State: Zip: <br />3. Corporation <br />Legal name of corporation: DEWIN-rE2 / NC <br />Date and state of incorporation: ) fi NU A P y l R9'3 <br />List officers and directors who own 15% or more of stock: <br />Name#1: J-30NAi-O t--, br-WINTEk <br />Title: cAmE2 am P'r'esI e-,dt <br />Business Address:_ 1POA 1-I1ucoL-A7 6t��EttSt <br />city: Sou'/-h bid State: /N zip: L/660! <br />Residential Address:_ /013 1-1fleozw (,VAY LjeS`t <br />City: M150Y)mK4 State: /N Zip: LlbsgU <br />Name#2:_ kRfzA%ETl+ /+- /fir: WINrcl2 <br />Title: eo- o ivAmr• alvLd V/CE - 19('es t /JEn/'t <br />Business Address: &4)d 47NGOL/Lt WA-Y Et15f <br />City: :50uy'h 6e4 State: J N Zip: r F & 6 01 <br />Residential Address: 1d13 1-INCoLN WAY Gtrz5sr <br />City: M I5N414)g K 4 State: r N zip: qbS-'/w <br />