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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 (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Title: <br />Business Address: <br />City: <br />Residential Address: <br />City: <br />IV. PERSONAL DATA <br />State: <br />State: <br />Zip: <br />Zip: <br />A. Applicant's Legal Name: 0 dJPrc 0 L 66 W1AJr6/' <br />B. Residential Address: !0 13 41Ncot nJ lNg y /0 CY7' <br />City: M 16H/RWAK-d7 State: //V Zip: 4(0 �! <br />C. Residential Telephone Number: 5 7y - oz S 5 =-6-7U / <br />D. Residential Fax Number: <br />E. Celephone Number: <br />F.E-Mail Address: e, dti'r (a sl7cgLlobal.ne% <br />G. Position with business: /9 to A&P_ cWvl d/ 17&t' ' <br />H. Please list all criminal convictions (if any), excluding traffic <br />Nature of Conviction <br />(Attach additional sheets if necessary) <br />City State <br />I. Please list all addresses forthree (3) years prior to application date: <br />Street Address <br /><' A- Mom- F}- 5 <br />A6oU� 5/A/6E /97/ <br />(Attach additional sheets if necessary) <br />J. Date of birth: <br />K. Gender: Ma le- <br />L. Social Security Number: <br />M. Race: w lde- <br />City State <br />Date <br />Dates <br />