Facility Role

21482

Agency Interest ID

18711

Facility ID

Active

Facility Status

Class C Operator on Duty

Facility Contact

Role

Entity Type

Ownership Type

Ownership Type Other

Effective Date

Proposed End Date (MM/DD/YYYY)

Business/Public Agency/Other Entity

Can't Find Business

Business Name

Business ID (From the Secretary of State)

Owner Entity Number

Individual Name

Can't Find Individual

Prefix

Owner Entity Number

First Name

OSFM ID

Job Title

Last Name

Suffix

Business Name/Individual Name

Peoplesoft Customer ID

Telephone Number

Address

I have met the financial responsibility requirements (in accordance with 329 IAC 9-8)

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