Free 47919.FH11 - Indiana

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APPLICATION FOR APPROVAL OF AUCTIONEER PRELICENSING COURSE PROVIDER OR CONTINUING EDUCATION COURSE SPONSOR
State Form 47919 (R2 / 7-07)

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

INSTRUCTION: Please type or print legibly
Please check applicable box:

Prelicensing Course Provider

Continuing Education Course Sponsor

PROVIDER / SPONSOR INFORMATION
Name of provider / sponsor

Name of director / contact person

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

Business telephone number

FAX number

(
Web address

)

(
E-mail address

)

PARTNERSHIP / CORPORATION / LLC / LLP INFORMATION

If the ownership of the provider / sponsor is a partnership, LLC / LLP or corporation, please check applicable box and provide names and addresses of partners, officers, directors or members / managers on a separate paper: Partnership LLC / LLP Corporation
PRELICENSING COURSE PROVIDER INFORMATION ONLY

Please indicate instructors and include evidence that they comply with 812 IAC 2-3-2.
NAME(S) NAME(S)

CONTINUING EDUCATION COURSE SPONSOR INFORMATION ONLY

Please provide a descriptive course content outline for each course including a cover sheet indicating the course title (indicate the course subject if not in title) and number of continuing education hours. Also, please provide a copy of the certificate of course completion. I (we) the undersigned, do hereby swear and affirm that: 1) The sponsor shall provide to all licensees who successfully complete an approved course a certificate of course completion pursuant to 812 IAC 3-1-6; 2) Each instructor meets the qualification pursuant to 812 IAC 3-1-7; 3) The sponsor will conduct an instructor and course evaluation and that such shall be provided to the commission upon request pursuant to 812 IAC 3-1-2 (b) (9). 4) Each facility shall meet the requirements of 812 IAC 2-2-1.
APPLICATION AFFIRMATION

I (we) the undersigned, submit this application in conformance with IC 25-6.1 and 812 IAC pertaining to auctioneer prelicensing course provider and or continuing education course sponsor approval. I (we) understand that any violations of the license law or rules on my (our) part will subject me (us) to loss of approval.
Signature of principal officer, partner, manager, school director Date (month, day, year)