Free 48444.FH11 - Indiana

APPLICATION FOR FUNERAL HOME BRANCH LICENSE
State Form 48444 (R2 / 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).

* Your Federal Identification 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 funeral home branch

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

Telephone number

E-mail address

Federal Identification number *

(

)
License number of funeral home

Name of funeral home with which branch is affiliated

Name of manager in charge of funeral home branch

License number of manager

Names and license numbers of all funeral directors / embalmers and funeral director interns who will be performing services at, or on behalf of, the funeral home branch:
Name License number

Name

License number

Name

License number

Name

License number

VERIFICATION AND SIGNATURE 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 applicant Date (month, day, year)