Form 18476 - Application For Auction House/company License
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APPLICATION FOR AUCTION HOUSE/COMPANY LICENSE
INDIANA AUCTIONEER COMMISSION
PROFESSIONAL LICENSING AGENCY
State Form 18476 (R7 / 7-07)
402 West Washington Street, Room W072
Approved by State Board of Accounts, 2007
Indianapolis, IN 46204-2700
Telephone: (317) 234-3040
E-mail: pla11@pla.IN.gov
INSTRUCTIONS: Please type or print legibly.
*
Your Social Security number is being requested by this state agency in accordance with
I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.
FOR OFFICE USE ONLY
DATE LICENSE ISSUED
DATE FEE PAID
LICENSE NUMBER
RECEIPT NUMBER
DO NOT WRITE ABOVE THIS LINE
Please check one only:
Auction House
Auction Company
Identify whether:
Individual
Corporation
Limited Liability Company
Partnership
Trust
Firm
Association
INFORMATION ABOUT THE BUSINESS
Name of business
Address (number and street, city/town, county, state, and ZIP code)
Mailing address (number and street, city/town, county, state, and ZIP code)
Web address
E-mail address
INFORMATION ABOUT THE INDIVIDUAL, MEMBERS, OR OFFICERS
Name
Title
*
Resident address (number and street, city/town, county, state, and ZIP code)
Social Security number
Name
Title
*
Resident address (number and street, city/town, county, state, and ZIP code)
Social Security number
Name
Title
*
Resident address (number and street, city/town, county, state, and ZIP code)
Social Security number
INFORMATION ABOUT THE LICENSED AUCTIONEER(S) CONDUCTING AUCTIONS
Name
License number
Resident address (number and street, city, state, and ZIP code)
Name
License number
Resident address (number and street, city, state, and ZIP code)
Name
License number
Resident address (number and street, city, state, and ZIP code)
APPLICATION AFFIRMATION
I affirm, under the penalties of perjury, that the information, statements, and any attachments made in conjuction with this application
are true, correct, and complete.
Signature of applicant
Date (month, day, year)
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