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Form 45268 - Application For Funeral Home Licence - Indiana State Board Of Funeral And Cemetery Service - 2003 Page 2

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

Name

License number

Name

License number

Name

Undersigned acknowledges as the applicant or on behalf of the applicant that the funeral home may not be operated without having a funeral director either

perform or directly supervise each act of funeral service performed for the funeral home.

Undersigned swears to or affirms the truth of the foregoing.

Signature of applicant or applicant’s agent

Title of the signed agent if applicant

NOTARY CERTIFICATE (SWORN OATH)

STATE OF ____________________________________________

}

SS:

COUNTY OF __________________________________________

I, __________________________________________________________________________, having been duly sworn on oath, say that I am the

above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.

Signature of applicant