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Get Indiana Form 42235

OFFICE USE ONLY APPLICATION FOR AMUSEMENT ENTERTAINMENT PERMIT Permit number State Form 42235 R4 / 11-05 Approved by State Board of Accounts 2006 Receipt number INSTRUCTIONS Return to Department of Homeland Security Division of Fire Safety Permit Division 402 West Washington Street Room E241 Indianapolis IN 46204 Theater Assembly Hall Name of facility Dance Hall Roller Rink Night Club Lodge Hall Cabaret Carnival Fair City Special Event Gymnasium .

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