Form 45168 - Application For Funeral Home License
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APPLICATION FOR FUNERAL HOME LICENSE
STATE BOARD OF FUNERAL & CEMETERY SERVICE
PROFESSIONAL LICENSING AGENCY
State Form 45268 (R6 / 10-09)
402 West Washington Street, Room W072
Approved by State Board of Accounts, 2009
Indianapolis, Indiana 46204
(317)-234-3031
INSTRUCTIONS:
Include the license fee (call or visit our website for current fees).
* Your Federal Identification number is being requested by this state agency in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
The number will be given to the Department of Revenue.
FOR OFFICE USE ONLY
Application fee
Date fee paid (month, day, year)
Receipt number
License number issued
Date license issued (month, day, year)
License obtained by
DO NOT WRITE ABOVE THIS LINE
Name of funeral home
Federal Identification number *
Address of funeral home (number and street, city, state, and ZIP code)
T elephone number
E-mail address
(
)
If purchase of a previously licensed funeral home, indicate license number of that funeral home
Have pre-need contract holders been notified of the sale of the funeral home?
Yes
No
If yes, include a sample copy of the letter.
If no, when will the notice be mailed? _____________________________________
Name of owner
Type of owner (check one)
Sole proprietor
Partnership
Corporation
Address (number and street, city, state, and 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, and ZIP code)
Name of the manager who will be in charge of the funeral home
License number
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
I understand that providing fraudulent information may be grounds for refusal to issue the license for which I am applying or for disciplinary action against
the license which may be issued.
Signature of applicant
Date (month, day, year)
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Parent category: Business