Form 8521 - Licensure Certification Request - Indiana Professional Licensing Agency
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1
2Indiana State Board of Funeral and Cemetery Service
LICENSURE CERTIFICATION REQUEST
Indiana Professional Licensing Agency
302 W. Washington St., Rm. E034
State Form 8521 (R2 / 7-99)
Indianapolis, Indiana 46204-2700
Approved by State Board of Accounts, 1993
Telephone: (317) 232-2980
INSTRUCTIONS: Complete the top portion of this page and forward to the state in which you are currently licensed.
Name (last, first, middle, maiden)
Address (Street, city state ZIP code)
License number
Date of issuance
I hereby authorize the ________________________________________ Board of Funeral Service to furnish the Indiana Funeral Service Board the
(State of original licensure)
information requested below.
Signature
Date
APPLICANT: DO NOT WRITE BELOW THIS LINE - FOR LICENSING AGENCY USE
The above named person has applied for a license by reciprocity to practice funeral service in INDIANA. Please complete the following information and
return to this office.
LICENSE TYPE
LICENSURE REQUIREMENT
Embalmer
Embalmer examination
Funeral director
Funeral director examination
Combination thereof
Combination thereof
EDUCTIONAL REQUIREMENTS
1. Premortuary school education required. (Check one)
Embalmer
Yes
No
Funeral director Yes
No
Combination
Yes
No
2. Length of mortuary course required:
Embalmer
Yes
No
Funeral director Yes
No
Combination
Yes
No
3. Required years of internship
Embalmer
Yes
No
Funeral director Yes
No
Combination
Yes
No
4. Other:
CERTIFICATION
I, __________________________________________________ , Secretary of the ____________________________________________ certify that
Name of board
____________________________________________ was granted embalmer license number _______________________ on the _______ day of
Name of applicant
_______________________________, _________ ; and / or funeral director license number _________________________ on the ________ day of
_________________ ; or combination thereof, license number _____________________________________________ and that said license(s) have
been renewed for the year ending on the _______ day of ____________________, __________ .
I, further certify that _______________________________________________________ obtained the following scores on the written examinations:
Name of applicant
Embalmer:
Score:
Date of examination:
Passing score:
Funeral director:
Score:
Date of examination:
Passing score:
Other:
Score:
Date of examination:
Passing score:
(Continued on reverse side)
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