Free 45268.FH11 - Indiana

APPLICATION FOR FUNERAL HOME LICENSE
State Form 45268 (R5 / 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).

* 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. The number will be given to the Department of Revenue.

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 Address of funeral home (number and street, city, state, and ZIP code) T elephone number E-mail address Federal Identification number *

(

)

If purchase of a previously licensed funeral home, name and address of previous funeral home (number and street, city, state, and ZIP code) Name of owner Address (number and street, city, state, and ZIP code) Type of owner (check one)

Sole proprietor

Partnership

Corporation

Names, titles and principal addresses of residence of the partners, directors or other executive officers: NAME TITLE ADDRESS (number and street, city, state, and ZIP code)

Name of the manager who will be in charge of the funeral home

License number

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: NAME LICENSE NUMBER

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)