Free 45265.FH11 - Indiana

APPLICATION FOR FUNERAL DIRECTOR LICENSE BY RECIPROCITY
State Form 45265 (R4 / 7-08) 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

Date of birth (month, day, year)

Social Security number *

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

Telephone number

State originally licensed by

Embalmer number

Funeral license number

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Attached is certification of licensure by said state, a certified copy of college transcripts or department of mortuary science diploma, and a copy of the National conference Examination passing scores. I acknowledge that after my application is reviewed and approved by the State Board of Funeral and Cemetery Service, I will be scheduled for the next available Funeral Director Examination. 1. Have you been convicted of a crime (felony or misdemeanor)? If yes, please attach supporting documentation relevant to the conviction. Yes No

2. Have you ever had any complaint filed against you with the State Board of Funeral and Cemetery Service or with the Funeral and Cemetery Board of any other state? Yes No If yes, please explain on a separate sheet of paper and include documentation. 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)