Free 47332.FH11 - Indiana

Reset Form APPLICATION FOR CEMETERY REGISTRATION
State Form 47332 (R4 / 7-08) Approved by State Board of Accounts, 2008

INSTRUCTIONS: Please include the registration fee. (Call or check our website for current fee)

INDIANA STATE BOARD OF FUNERAL AND CEMETERY SERVICE PROFESSIONAL LICENSING AGENCY 402 W. Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3031 www.pla.IN.gov

*Your federal ID number is being requested in accordance with IC 4-1-8-1; Disclosure is mandatory. The number will be given to the Department of Revenue. FOR OFFICE USE ONLY

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER

LICENSE NUMBER ISSUED DATE LICENSE ISSUED (month, day, year) LICENSE OBTAINED BY DO NOT WRITE ABOVE THIS LINE

Name of cemetery Address of cemetery (number and street, city, state, and ZIP code) Telephone number E-mail address Federal Identification number *

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If this is a purchase of a previously licensed cemetery, provide the previous cemetery name and registration number here.

(check applicable category) sole proprietor Name of owner Address (number and street, city, state, and ZIP code) if applicable partnership corporation association other organization

NAMES, TITLES AND PRINCIPAL ADDRESSES OF THE PARTNERS, DIRECTORS OR OTHER EXECUTIVE OFFICERS
Name Title Address (number and street, city, state, and ZIP code) Name Title Address (number and street, city, state, and ZIP code)

Name Title Address (number and street, city, state, and ZIP code)

Name Title Address (number and street, city, state, and ZIP code)

Name Title Address (number and street, city, state, and ZIP code)

Name Title Address (number and street, city, state, and ZIP code)

I certify that I personally completed this application and that the information appearing hereon is true and correct to the best of my knowledge and belief. I understand that providing fraudulent information may be grounds for refusal to issue the license for which I am applying or for disciplinary action against the license which may be issued.
Signature of authorized cemetery representative Printed or typed name of authorized cemetery representative Date signed (month, day, year)