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APPLICATION FOR AUCTION HOUSE/COMPANY LICENSE
State Form 18476 (R7 / 7-07) Approved by State Board of Accounts, 2007

INDIANA AUCTIONEER COMMISSION PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204-2700 Telephone: (317) 234-3040 E-mail: [email protected]

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 FEE PAID RECEIPT NUMBER DATE LICENSE ISSUED LICENSE NUMBER DO NOT WRITE ABOVE THIS LINE
Please check one only: Identify whether:

Auction House Individual Corporation

Auction Company 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 Resident address (number and street, city/town, county, state, and ZIP code) Name Resident address (number and street, city/town, county, state, and ZIP code) Name Resident address (number and street, city/town, county, state, and ZIP code) Title Social Security number * Title Social Security number * Title Social Security number *

INFORMATION ABOUT THE LICENSED AUCTIONEER(S) CONDUCTING AUCTIONS
Name Resident address (number and street, city, state, and ZIP code) Name Resident address (number and street, city, state, and ZIP code) Name Resident address (number and street, city, state, and ZIP code) License number License number License number

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)