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For all municipal business limnse questions, wntaet City of South Bend • Department of Community Investment <br />227 West Jefferson BIW • Suite 1400 S •South Bend, Indiana 4901 • 5M235.5912 • F: 57C235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. Corporation (Continued) <br />Name #3: <br />Residential Address: <br />IV. PERSONAL DATA <br />A. Applicant's Legal Nam <br />B. Residential Address: <br />city:.,39x6, 12e,4 State: ZN Zip: 4CIj60 / <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number: ely 13 <br />F. E-Mail Address:. IAJeek 16dl CCVV\ <br />G. Position with business: (�,)Ae. <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 />2,16 w ->W <br />pC <br />CA LL <br />>"O-) 0 , s-. <br />2Bo3 S <br />Aga -ilex <br />Ave -'LL <br />>,o2o.S-- <br />E➢ <br />