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Form 45268 - Application For Funeral Home Licence - Indiana State Board Of Funeral And Cemetery Service - 2003

APPLICATION FOR FUNERAL HOME LICENSE

State Board of Funeral and Cemetery Service

302 W. Washington St., Rm. E034

State Form 45268 (R4 / 4-03)

Indianapolis, IN 46204

Approved by State Board of Accounts, 2003

317-232-2980

For an application filed on or before the last day of an even numbered year.

FEE: $25.00 -

For an application issued during an odd numbered year.

FEE: $50.00 -

LICENSE RENEWAL:

A license issued in an odd numbered year, must be renewed by the 31st day of December in the next year.

Your Federal ID number is being requested in accordance with IC 4-1-8-1; disclosure is mandatory. The number will be given to the Department

of Revenue.

Name of funeral home

Address of funeral home (number and street)

(city, state, ZIP code)

T elephone number

Federal ID number *

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

Name of: (check applicable category)

sole proprietor

partnership

corporation

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

Principal address of residence of sole proprietor (number and street, city, state, ZIP code)

Names, titles and principal addresses of residence of the partners, directors or other executive officers:

Name

Title

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

Name

Title

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

Name

Title

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

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

License number

(Continued on the reverse side)

Form 45268 - Application For Funeral Home Licence - Indiana State Board Of Funeral And Cemetery Service - 2003