IEEA Membership form 2010 Name * Phone * Mailing Address, City, State, Zip * email address * Name of Funeral Home * Address of Funeral Home, City, State, Zip * License Number * You may print this form and mail with a check made payable to Indiana Public Health Foundation, Inc., 3512 Rockville Road, Suite 159-D, Indianapolis, IN 46222. Or you may choose to pay with a credit card by clicking on Submit Form.