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For all municipal business license questions, contact: City of South Bend • Cepa"me ntuf Community In"Amerd <br />222 West Jefferson BIM • suiR 340n S •South Bend, Indiana 46601 • 524.235 5912 • F:524.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name N3: <br />Business Address: <br />Residential Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal <br />B. Residential Add <br />C. Residential Telephone Numbek ORU 64LI-6w <br />D. Residential Fax <br />E. Cellphone Numb <br />F. E-Mail Address: <br />G. Position with business: AVWX i <br />H. Please list all criminal convictions Ill 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 />