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For all municipal business license questions, ctn na: City of South Be • Department of Community Investment <br />227West Jefferson Blvd • Suite lEW 5 •South Bend, IMlana E6601 1576235.5912 • F:59E33SM21 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />Ill. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: Zzeeo�b-49 z4er vir3 <br />B. Residential Address: zll "g` !Y CZ4"11=4 -AP/9 <br />City: i✓/Gyittee,;A Ff} State: /A/ ip: /�65905 <br />C. Residential Telephone Number:_y�-399 <br />D. Residential Fax Number: � <br />E. Celephone Number: <br />F.E-Mail Address: <br />G. Position with business: 4Jiiidf� <br />H. Please list all criminal convictions If any), excluding trafficviolations: <br />Nature of Conviction City State Date <br />(Attach additional sheets if necessary) <br />I. Please list all addresses for three (3) years prior to application date: <br />Stree[Adlress City State9 Dates <br />