Free APPLICATION FOR LICENSE - Indiana

RENEWAL APPLICATION FOR LICENSE TO OPERATE A PERSONAL SERVICES AGENCY
State Form 53591 (4-08) Approved by State Board of Accounts, 2008

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Indiana State Department of Health-Division of Acute Care
(Pursuant to IC 16-27-4)

Division of Acute Care Use Only Date Received (month, day, year) __________________ Date Approved (month, day, year) __________________

All questions on this application must be answered completely and legibly with printed or typed script with supporting documentation attached when applicable. Complete all sections on this application. AN INCOMPLETE OR ILLEGIBLE APPLICATION WILL BE RETURNED WITHOUT BEING PROCESSED. A non-refundable application fee in the amount of $250.00 must accompany this application. No license or approval shall be issued without receipt of this fee and/or completed application. Please Type or Print Legibly SECTION I - LABEL IDENTIFICATION/INFORMATION
Agency Name/Address Identification Label

If there is a change in the name of the agency submit Articles of Incorporation or Certificate of Assumed Business Name or applicable document from the State of Indiana Office of the Secretary of State. Complete all sections of the application.

SECTION II - AGENCY NAME AND ADDRESS Practice Location (agency) Complete all sections below
Name of agency

Street address (number and street)

P.O. Box

City

County

Zip code +4

Telephone number ( )

Fax number ( )

E-Mail address

Web address

SECTION III- MANAGEMENT Staffing - Complete all sections below (If there are changes in your staffing submit a current limited criminal history check)
Name of Manager Name of Alternate Manager

SECTION IV ­ BRANCHES
Does the agency have branches? Yes No If yes, please provide the name, complete address, telephone number and county of each branch location. The branch must be located within 120 miles of the parent. Refer to IC 16-27-4-6. Submit map to reflect the mileage from parent to branch. (Use additional sheet if necessary.) Name Address (street address/city/zip code and county) Telephone Number

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SECTON V - OWNERSHIP INFORMATION

A. Applicant Legal Entity (Direct Owner/Operator) Type or write name of corporation, limited liability company, partnership, etc and EIN Number. If a change of ownership occurred, you must request in writing a change of ownership application, complete and return to this
Department. Name of Applicant Legal Entity-Licensee (i.e. name of corporation, limited liability company or partnership) EIN number

B. Ownership Information (officers/directors/managing agents/managing employees of the personal services agency) Has the agency changed individuals with direct or indirect ownership? Yes No (If yes, complete below)
List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%) or more in the applicant entity. Indirect ownership interest is an entity that has an ownership interest in the applicant entity. Ownership in any entity higher in a pyramid than the applicant constitutes indirect ownership. (Use additional sheet if necessary.) Name Business Address (street address/city/state/zip code) EIN Number

C. Directors/Officers/ Partners/Managing Agents/Managing Employees (Director Owners) Has the agency changed officers, partners and/or directors? Yes No (If yes, complete below )
List all individuals (persons) associated with the applicant entity and indicate the individual's title (i.e. officer, director, member, partner, president, vice president, secretary, etc.) If the applicant is a partnership, list the name and title of each partner or the name and title of all individuals associated with each entity that forms the partnership. If the applicant is a Limited Liability Company, list the name and title for all individuals associated with each member entity that forms the Limited Liability Company. (Use additional sheet if necessary.) Officer/Partner/Director Name Title Business Address (street address/city/state/zip code) Telephone Number

SECTON VI - CERTIFICATION OF APPLICATION
The undersigned hereby makes application for a license to operate a Personal Services Agency (agency) in the State of Indiana, and in support of this application, represents and shows that the owners and operators are of reputable and responsible character, are able to comply with the personal services agency laws, IC 16-27-4, and will operate and maintain this agency in accordance with those requirements. I hereby certify that the operational policies of the agency will not provide for discrimination based upon race, color, creed or national origin. I swear or affirm under the penalty of perjury that all statements made in this application and any attachments thereto are correct and complete and that I will comply with all regulations, laws and rules governing the licensing of agencies in Indiana. Signature of the president/chairperson/CEO/Owner as indicated in Section V.A. and V.B. on this application. Signature of personal services agency manger as indicated in Section III on this application.
President/Chairperson/CEO/Owner ((typed/printed) Signature of President/Chairperson/CEO/Owner Date (month/day/year)

Personal Services Agency Manager ((typed/printed)

Signature of Personal Services Agency Manager

Date (month/day/year)

RETURN APPLICATION AND A NON-REFUNDABLE LICENSE FEE OF $250.00 TO: INDIANA STATE DEPARTMENT OF HEALTH ND ATTENTION: CASHIER, 2 FLOOR P.O. Box 7236 INDIANAPOLIS, INDIANA 46207

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