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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 />A. Applicant's Legal Name: <br />B. Residential A,d)dress: <br />City: <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Numl <br />F. E-Mail Address: <br />G. Position with bL <br />State: Zip: <br />ate: <br />H. Please list all criminal convictions (if any), excluding traffic violations: <br />Nature of Conviction City State <br />(Attach additional sheets if necessary) <br />I. Please list all addresses for three (3) years prior to application date: <br />Street Address City State <br />�C7 � YDL_ <br />(Attach additional sheets if necessary) <br />J. Date of birth:: <br />K. Gender: T. <br />L. Social Security Number: <br />M. Race: &L�U'L <br />3 <br />Zip: <br />Zip: <br />Date <br />Dates <br />--2023 <br />r 0 y <br />