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Reset Form APPLICATION FOR LICENSURE AS AN ANESTHESIOLOGIST ASSISTANT MEDICAL LICENSING BOARD OF INDIANA PROFESSIONAL LICENSING AGENCY 402 West Washington Street Room W072 Indianapolis Indiana 46204 Telephone 317 234-2060 E-mail pla3 pla.IN.gov www. 00 payable to the Indiana Professional Licensing Agency in accordance with 844 IAC 15-1-6. 2. All fees are non-refundable and non-transferable. Pla.IN.gov State Form 55969 R2 / 11-16 Approved by State Board of Accounts 2016 INSTRUCTIONS 1. The fee...
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