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For all municipal business license questions, coma¢ city ofsouth Bend • Department of Community Inwstment <br />227 West JeRerson BIW • Suite 1400 S -South Bend, Indiana 45601 • 570.235.5912 • F: 574.23SB021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION -4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name#3: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Name: <br />B. Residential Address: <br />City. s --Q • State: fA/ Zip: L� <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />F. E-Mail Address: 2 <br />G. Position with business: <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 />Street Address City State Dates <br />Q�S f <br />