Free 28138.FH11 - Indiana

APPLICATION FOR FUNERAL DIRECTOR INTERN LICENSE
State Form 28138 (R5 / 6-08) 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:

Include the license fee (call or visit our website for current fees) and a photograph of yourself with your completed application.

* 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) Social Security number *

1. Have you been convicted of an act that would constitute a ground for disciplinary sanction under IC 25-15-8; or a crime that has a direct bearing on ability to practice competently? Yes No If yes, please attach supporting documentation relevant to the conviction. 2. I have graduated from an accredited high school and have successfully completed either (check applicable alternative): a. (i) thirty (30) semester hours of forty-five (45) quarter hours of college level work in a regionally accredited institution of higher education that includes course work in the subjects of English, Humanities, Science, Business, and other electives that apply toward a baccalaureate degree from the institution; and (ii) four (4) academic quarters or its equivalent in an accredited college, school, or department of mortuary science approved by the board. (Certified copies of the transcripts verifying the courses and grades completed must be enclosed.) b. A twenty-one (21) month program in an accredited college, school, or department of mortuary science approved by the board. (A letter of certification of graduation from the institution must be enclosed.) 3. I have attached a certification attesting to my passage of the funeral service intern examination required by the funeral and cemetery service board.
Date of examination (month, day, year) Examination score

4. I cannot engage in the practice of funeral service as defined by IC 25-15-2-22 unless I am under the direct supervision of a funeral director licensed by the Indiana State Board of Funeral and Cemetery Service. 5. I am acting as the agent for the __________________________________________________________________________________ Funeral Home
Name of funeral home

located at _______________________________________________________________________________________________________________
Number, street, city, state, ZIP code and county

where I will be performing services as a funeral director intern. I acknowledge that I will notify the State Board of Funeral and Cemetery Service of any change of funeral home where I will be acting as a funeral director intern.

VERIFICATION AND SIGNATURE I do hereby 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 (month, day, year)