State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center Page 3

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J. Officers (if the business entity is incorporated)
Position
Name
Address/City/State/Zip
President/Chairperson/CEO
Vice-President/Vice-Chairperson/COO
Treasurer/CFO
Secretary
K. Ownership and/or Change in Ownership:
List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%)
in the applicant entity. Indirect ownership interest is an entity that has an ownership interest in the applicant entity. Ownership in any
entity higher in a pyramid than the applicant constitutes indirect ownership. (use additional sheet if necessary)
Name
Business Address/City/State/Zip
EIN Number
CERTIFICATION OF APPLICATION
The undersigned hereby makes application for a license to operate an Ambulatory Outpatient Surgical Center (Center) in the State of
Indiana, and in support of this application, represents and shows that the owner(s) and operator(s) are of reputable and reasonable
character, are able to comply with the Ambulatory Outpatient Surgical Center statues, IC 16-21, and the rules promulgated thereunder,
410 IAC 15-2.1 and will operate and maintain this center in accordance with those rules.
I certify that the operational policies of the center will not provide for discrimination based upon race, color, creed, or national origin.
I swear and affirm under the penalty of perjury that all statements made in this application and any attachments thereto are correct and
complete and that I will comply with all regulations, laws, and rules governing the licensing of centers in Indiana.
Signature of Chief Executive
Officer/Owner:
Printed Name and Title:
Date of Signature:
Signature of the Facility
Administrator:
Printed Name and Title:
Date of Signature:
See the following page for instructions regarding licensure fees and submission
of this application
3

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