Form 47332 - Application For Cemetery Registration
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1Indiana State Board of Funeral and Cemetery Service
APPLICATION FOR CEMETERY REGISTRATION
302 W. Washington Street, Room E034
State Form 47332 (R3 / 2-04)
Indianapolis, IN 46204
FEE: $100.00
Approved by State Board of Accounts, 2004
*Your federal ID number is being requested in accordance with IC 4-1-8-1; however, disclosure is not mandatory. The number will be given to the
Department of Revenue.
Name of cemetery
Address of cemetery (number and street, city, state, ZIP code)
Telephone number
Federal ID number *
If this is a purchase of a previously licensed cemetery, provide the previous cemetery name and address here
(check applicable category)
sole proprietor
partnership
corporation
association
other organization
Name of sole proprietor (if applicable)
Principal address of residence of sole proprietor (number and street, city, state, ZIP code) if applicable:
NAMES, TITLES AND PRINCIPAL ADDRESSES OF THE PARTNERS, DIRECTORS OR OTHER EXECUTIVE OFFICERS
Name
Name
Title
Title
Address (number and street, city, state, ZIP code)
Address (number and street, city, state, ZIP code)
Name
Name
Title
Title
Address (number and street, city, state, ZIP code)
Address (number and street, city, state, ZIP code)
Name
Name
Title
Title
Address (number and street, city, state, ZIP code)
Address (number and street, city, state, ZIP code)
NOTARY CERTIFICATE (SWORN OATH)
STATE OF ________________________________________________________
}
SS:
COUNTY OF ______________________________________________________
I, ________________________________________________________________________________________ having been duly sworn on oath, say
that I am the authorized representative of the cemetery making application for registration, that I have personally prepared the foregoing application, and
that the same is true to the best of my knowledge and belief.
Signature of authorized cemetery representative
Signature of Notary Public
Printed or typed name of authorized cemetery representative
Printed or typed name of Notary Public
Date commission expires
Date subscribed and sworn to Notary Public
County of residence
(If additional space is required, use the back ot this form)
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Parent category: Financial