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5 <br />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 /> <br />LICENSE APPLICATION FOR – CHARITABLE SOLICITATION <br />MUNICIPAL CODE SECTION - 4-55 <br />V. PERSONAL DATA (Continued) <br />APPLICANT 3 (Continued) <br />C. Residential Telephone Number: <br />D. Residential Fax Number: <br />E. Cellphone Number: <br />F. E-Mail Address: <br />G. Position with business: <br />H. Date of birth: <br />I. Gender: <br />J. Social Security Number: <br />K. Race: <br /> <br />VI. IF PROFESSIONAL SOLICITORS ARE USED, INCLUDE COPIES OF <br />A. State of Indiana Consultant/Solicitor Registration. <br />B. Contract between Consultant/Solicitor and Applicant. <br /> <br />VII. IF APPLICANT IS A CORPORATION, INCLUDE COPY OF <br />A. Resolution authorizing solicitation for which application is filed. <br /> <br />VIII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br /> <br />IX. AFFIRMATION <br /> <br />I, hereby, certify and affirm that all of the information I have given in this application is true and <br />accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. I understand that the <br />completed application must be filed no less than thirty (30) days before the proposed <br />beginning date of the solicitation. I have read and understand the regulations of the Charitable <br />Solicitations license found in the City of South Bend Municipal Code, Section 4-55. Finally, I <br />understand that, if registration and a permit are granted, it will not be used or represented in <br />any way or manner, that such is an endorsement by the City of South Bend or by any <br />Department or Officer thereof. <br /> <br /> <br /> <br /> <br />Signature Date