Free 48961.FH11 - Indiana

APPLICATION FOR CERTIFICATE OF AUTHORITY
State Form 48961 (R3 / 6-08) Pursuant to IC 30-2-13-33.

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STATE BOARD OF FUNERAL & CEMETERY SERVICE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 (317) 234-3031 www.pla.IN.gov

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

Seller means a person, a firm, a limited liability company, a corporation, an association, or a partnership contracting to provide services or merchandise, or both, to a named individual or contracting to provide or sell both a contract and a funding mechanism to be used in conjunction with the purchase or services or merchandise. (IC 30-2-13-10)
Name of seller Telephone number

(
Business address of seller (number and street, city, state, and ZIP code)

)

I hereby affirm that the above named seller is of good moral character, operates using fair business practices, and has not been convicted of a criminal offense.
If this application is being filed due to the purchase of a previously licensed funeral home / cemetery, provide the name of the previous funeral home / cemetery.

Address of previously licensed funeral home / cemetery (number and street, city, state, and ZIP code)

The following persons have authority to directly represent the above named seller as agents: NAME ADDRESS (number and street, city, state, and ZIP code) SOCIAL SECURITY NUMBER *

I certify that I personally completed this application, and that the information 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 seller or partner or officer of seller Date (month, day, year)

Printed name of individual signing

Title of individual signing