Fillable Form 47332 - Application For Cemetery Registration printable pdf download

Form 47332 - Application For Cemetery Registration

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APPLICATION FOR CEMETERY REGISTRATION

INDIANA STATE BOARD OF FUNERAL AND CEMETERY SERVICE

PROFESSIONAL LICENSING AGENCY

State Form 47332 (R4 / 7-08)

402 W. Washington Street, Room W072

Approved by State Board of Accounts, 2008

Indianapolis, IN 46204

Telephone: (317) 234-3031

INSTRUCTIONS:

*Your federal ID number is being requested in accordance with IC 4-1-8-1;

Please include the registration fee. (Call or check our website

Disclosure is mandatory. The number will be given to the Department of Revenue.

for current fee)

FOR OFFICE USE ONLY

APPLICATION FEE

LICENSE NUMBER ISSUED

DATE LICENSE

DATE FEE PAID (month, day, year)

ISSUED (month, day, year)

RECEIPT NUMBER

LICENSE OBTAINED BY

DO NOT WRITE ABOVE THIS LINE

Name of cemetery

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

Telephone number

E-mail address

Federal Identification number *

(

)

If this is a purchase of a previously licensed cemetery, provide the previous cemetery name and registration number here.

(check applicable category)

sole proprietor

partnership

corporation

association

other organization

Name of owner

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

NAMES, TITLES AND PRINCIPAL ADDRESSES OF THE PARTNERS, DIRECTORS OR OTHER EXECUTIVE OFFICERS

Name

Title

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

Name

Title

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

Name

Title

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

I certify that I personally completed this application and that the information appearing hereon is true and correct to the best of my knowledge and belief.

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 authorized cemetery representative

Date signed (month, day, year)

Printed or typed name of authorized cemetery representative