Form 48961 - Application For Certificate Of Authority - Indiana Professional Licensing Agency

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APPLICATION FOR CERTIFICATE OF AUTHORITY

STATE BOARD OF FUNERAL AND CEMETERY

Indiana Professional Licensing Agency

State Form 48961 (R2 / 12-99)

302 W. Washington St., Rm E034

Application for a Certificate of Authority to sell prepaid services and merchandise in

Indianapolis, Indiana 46204-2700

the State of Indiana in compliance with IC 30-2-13-33.

(317) 232-2980

"Seller" means a person, a firm, a limited liability company, a corporation, an association, or a partnership contracting to provide services or merchandise,

or both, to a named individual or contracting to provide or sell both a contract and a funding mechanism to be used in conjunction with the purchase or

services or merchandise. (IC 30-2-13-10)

Name of seller:

Telephone number

(

)

Business address of seller: (number and street, city, state, ZIP code)

I hereby affirm that the above named seller is of good moral character, operates using fair business practices, and has not been convicted of a criminal

offense.

If this is a purchase of a previously licensed funeral home or cemetery, provide the previous funeral home / cemetery name and address here

The following persons have authority to directly represent the above named seller as agents:

NAME

SOCIAL SECURITY NUMBER *

ADDRESS

* The request for your Social Security number is mandatory according to IC 4-1-8-1 and this application cannot be processed without it.

I hereby affirm that the statements herein are true and correct.

Signature of seller or partner or officer of seller

Printed name and title of individual signing

STATE OF INDIANA

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