Free VARIANCE APPLICATION - Indiana

APPLICATION FOR REGULATED EXPLOSIVE USE OPERATOR LICENSE (675 IAC 26-2-4)
State Form 52489 (R / 3-06) Approved by State Board of Accounts, 2006

INDIANA DEPARTMENT OF HOMELAND SECURITY Registration and Certification 302 West Washington Street, E239 Indianapolis, IN 46204 Telephone: (800)666-7784 or (317) 233-0208 www.in.gov/dhs/training/certregsection.html

A person/company who takes possession of a regulated explosive in the State of Indiana for the purpose of detonation under the person's direction or control shall submit an application to become a licensed regulated explosive use-operator. Fee-$350.00

Please Print Applicant Name:

Federal I.D. # or Last 4 digits of S.S.# Telephone Number

Business Name: Last Address: Street E-mail: City: First Middle Initial

Fax

State:

ZIP Code:

Drivers License/State ID Number Required:

I hereby affirm under penalty of perjury that all of the information provided with this application is true and correct: Signature: _________________________________________ Date: _________________________________________

APPLICATION FOR REGULATED EXPLOSIVE USE-OPERATOR LICENSE (675 IAC 26-2-4) CREDIT CARD PAYMENT Payment of the fee shall be by credit card, check or money order payable to the Indiana Department of Homeland Security and must accompany this application. If paying by credit card, please fill out the form below and mail it to the above address or fax it to 317/233-0497. The application must include payment of the license fee of $350.00.
Full Name on Credit Card: _____________________________________________________________ Billing Address Street:____________________________________________________________________________ City:___________________________________ State _____________ ZIP Code _______________ Phone Number:___________________________________ Credit Card (check one): Visa MasterCard

Account Number: _____________________________________________ Expiration Date (month/year): ______ / _______ CVV2 Number (last 3 digits of the number in the signature block on the back of the card): _________ By signing, Cardmember agrees to the obligations set forth by the Cardmember's Agreement with the issuer. ______________________________________________ Signature