Free 45267.FH11 - Indiana

APPLICATION FOR FUNERAL DIRECTOR EXAMINATION
State Form 45267 (R5 / 8-08) Approved by State Board of Accounts, 2008

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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

INSTRUCTIONS:

1. 2. 3.

Include the license fee (call or visit our website for current fees) and a photograph of yourself with your completed application. All supervised practice must be verified by a licensed funeral director on the reverse side of this form or by separate affidavit. Service for one funeral home during two different periods of time must be verified by separate affidavits.

* 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.

FOR OFFICE USE ONLY
Application fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year) Receipt number License obtained by

DO NOT WRITE ABOVE THIS LINE
Name of applicant Address (number and street, city, state, and ZIP code) T elephone number Funeral director intern license number E-mail address Social Security number *

(

)

I have worked under the direct supervision of the following funeral director licensees, having at least one (1) year of continuous experience in the practice of funeral service:
Name of funeral director Name of funeral home Address of funeral home (number and street, city, state, and ZIP code) Beginning date of service (month, day, year) Name of funeral director Name of funeral home Address of funeral home (number and street, city, state, and ZIP code) Beginning date of service (month, day, year) Ending date of service (month, day, year) Ending date of service (month, day, year) License number License number License number License number

Have you ever been convicted of a crime (felony or misdemeanor)? If yes, please attach supporting documentation relevant to the conviction.

Yes

No

I hereby verify that I have had one year of continuous experience in the practice of funeral service as defined by IC 25-15-2-22, under the direct supervision of funeral director(s) licensed by the State Board of Funeral and Cemetery Service during the aforementioned period(s) of time. I certify that I am the above named applicant, that I have personally prepared the foregoing application, and that the same 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 applicant Date signed (month, day, year)

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INTERNSHIP VERIFICATION BY FUNERAL DIRECTOR I, the , , , of

(Name of funeral director) (Name of funeral home) (License number)

(License number) (Location) (Name of intern)

, hereby verify that to

for the period ,has practiced funeral

from

(Month, day, year)

(Month, day, year)

service continuously under my direct supervision. I swear to or affirm the truth of the foregoing. STATE OF COUNTY OF

}

SS:

I ____________________________________________________, having been duly sworn on oath, say that I am the above-named supervising funeral director, that I have personally prepared the foregoing verification, and that the same is true 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 is being applied, for disciplinary action against the license which may be issued, and for disciplinary action against the license that I hold.
Signature of supervising funeral director Printed or typed name of supervising funeral director Date subscribed and sworn to Notary Public (month, day, year) Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires (month, day, year)

INTERNSHIP VERIFICATION BY FUNERAL DIRECTOR I, the , , , of

(Name of funeral director) (Name of funeral home) (License number)

(License number) (Location) (Name of intern)

, hereby verify that to

for the period ,has practiced funeral

from

(Month, day, year)

(Month, day, year)

service continuously under my direct supervision. I swear to or affirm the truth of the foregoing. STATE OF COUNTY OF

}

SS:

I ____________________________________________________, having been duly sworn on oath, say that I am the above-named supervising funeral director, that I have personally prepared the foregoing verification, and that the same is true 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 is being applied, for disciplinary action against the license which may be issued, and for disciplinary action against the license that I hold.
Signature of supervising funeral director Printed or typed name of supervising funeral director Date subscribed and sworn to Notary Public (month, day, year) Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires (month, day, year)

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