ࡱ>   ~/bjbjQFQF H3,3,R   QQ8dQaA"("""t$R')???????aCF?I1R$"t$I1I1?QQ""A;;;I1Q8""?;I1?;;P>>"k/Z1Th>p?1A0aAp>,G36G>>G>*,X;-.Q***??U7~***aAI1I1I1I1G********* :  DEPARTMENT OF FINANCIAL SERVICES Division of Funeral, Cemetery & Consumer Services 200 East Gaines Street Tallahassee, FL 32399- 0361   APPLICATION FOR COMBINATION FUNERAL DIRECTOR & EMBALMER LICENSE BY FLORIDA INTERNSHIP & EXAMINATION Under Section 497.376, Florida Statutes. Before the Board of Funeral, Cemetery and Consumer Services. REQUIRED FEES (Attach check or money order payable to Dept of Financial Services) (Nonrefundable) If application received in the period Sept. 1 of an odd year through Aug. 31 of an even yearIf application received in the period Sept. 1 of an even year through Aug. 31 of an odd year$100 Application Fee $242 Exam Fee (FL Law & Rules exam) $375 License fee $ 5 Unlicensed activity fee $722 Total fee due with application Add $50 if you desire a Provisional License$100.00 Application Fee $242.00 Exam Fee (FL Law & Rules exam) $187.50 License fee $ 5.00 Unlicensed activity fee $534.50 Total fee due with application Add $50 if you desire a Provisional License   FORMCHECKBOX  Check here if you desire issuance of a Provisional License. Please complete the application form for the Provisional or Temporary License, Application for Initial License. This application form is used by persons who desire, through a single application, to apply for a combination license as both a funeral director and embalmer. As used in this application, Division refers to the Division of Funeral, Cemetery and Consumer Services. Board refers to the Board of Funeral, Cemetery and Consumer Services. Unless specifically indicated otherwise, all questions and requests for data in this Application relate to the Applicant. Where the question calls for a YES or NO answer, circle the correct answer. FOR OFFICE USE ONLY If application received in the period Sept. 1 of an odd year through Aug. 31 of an even year BT TYCL FT V 2500 F $100 2500 E $242 2500 L $375 3800 F $ 5 $722 2502 T $ 50 If provisional license requested $772If application received in the period Sept. 1 of an even year through Aug. 31 of an odd year BT TYCL FT V 2500 F $100.00 2500 E $242.00 2500 L $187.50 3800 F $ 5.00 $534.50 2502 T $ 50.00 If provisional license requested $584.50 Section 1. PERSONAL INFORMATION First name:  FORMTEXT       Middle name (leave blank if none):  FORMTEXT       Last name:  FORMTEXT       Name Suffix (examples: Jr., II) (leave blank if none):  FORMTEXT       Birth Date (mm/dd/yyyy):  FORMTEXT      / FORMTEXT      / FORMTEXT      Section 2. RESIDENCE ADDRESSStreet Address (No PO Box allowed here):  FORMTEXT       Apartment:  FORMTEXT       # (leave blank if not applicable):City:  FORMTEXT      County:  FORMTEXT       State:  FORMTEXT      Zip Code:  FORMTEXT       Section 3. APPLICANT S PREFERRED MAILING ADDRESS FORMCHECKBOX Check here if mailing address is same as Residence address, then skip this section.Street or PO Box:  FORMTEXT       City:  FORMTEXT      County:  FORMTEXT      State:  FORMTEXT      Zip Code:  FORMTEXT       Section 4. PHONE & EMAILPrimary phone number: Area code:  FORMTEXT       Phone number:  FORMTEXT      -  FORMTEXT      E-Mail Address: (e.g., SmithJ@xyz.com)  FORMTEXT       Section 5. OTHER LICENSURE INFORMATION Check whichever applies to your situation:  FORMCHECKBOX a. I have completed, or am currently performing, a Florida internship.  FORMCHECKBOX b. I am licensed as a funeral director and embalmer in another state(s), and seek to substitute my practice in the other state(s) for the Florida internship requirements (complete and submit the form entitled Certification of Licensure in good standing in another state for each funeral director or embalmer license in another state). If you have completed, or are currently performing, a Florida funeral director and/or embalmer internship, please provide the following information concerning your Florida internship(s): c. Intern license or registration number:  FORMTEXT       d. Month & year intern license or registration was issued:  FORMTEXT       e. Is the internship completed? YES  FORMCHECKBOX  NO  FORMCHECKBOX  f. If your internship is completed, has your intern supervisor submitted a final quarterly intern supervisor s report? YES  FORMCHECKBOX  NO  FORMCHECKBOX  g. If internship has been completed, enter date completed:  FORMTEXT       h. If internship not completed, state the anticipated month & year of completion:  FORMTEXT       i. Is or was this a concurrent funeral director and embalmer internship? YES  FORMCHECKBOX  NO  FORMCHECKBOX Section 6. NATIONAL BOARD EXAMINATIONa. Have you taken the Arts Section of the National Board Exam (administered by the Conference of Funeral Service Examining Boards)? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If your answer to a. was YES: b. In what month and year did you take the Arts section of the National Board Exam:  FORMTEXT      / FORMTEXT       c. In what city and state did you take the Arts section of the National Board Exam:  FORMTEXT      / FORMTEXT       d. What was your score on the Arts section of the National Board Exam (if you took the exam more than once, state your highest score):  FORMTEXT       If your answer to a. was NO: e. In what month and year do you anticipate taking the Arts section of the National Board Examination:  FORMTEXT      / FORMTEXT       Your application is not complete until the Division receives an official report of your scores on the National Board Examination.f. Have you taken the Science Section of the National Board Exam (administered by the Conference of Funeral Service Examining Boards)? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If your answer to f. was YES: g. In what month and year did you take the Science section of the National Board Exam:  FORMTEXT      / FORMTEXT       h. In what city and state did you take the Science section of the National Board Exam:  FORMTEXT      / FORMTEXT       i. What was your score on the Science section of the National Board Exam (if you took the exam more than once, state your highest score):  FORMTEXT       If your answer to f. was NO: j. In what month and year do you anticipate taking the Science section of the National Board Examination?  FORMTEXT      / FORMTEXT       Your application is not complete until the Division receives an official report of your scores on the National Board Examination.Certification of Scores. If you answered YES to a. and/or f. above, attach to this application documentary evidence issued by the Conference of Funeral Service Examining Boards, showing which sections of the National Board Exam you took, and your scores on the sections of the National Board Exam which you took. If you took both sections of the National Board Exam, you must provide documentary evidence of your score on each separate section a combined aggregate score for both Sections is not acceptable.Section 7. ADVANCED EDUCATION REQUIREMENTa. Do you have a 2-year or 4-year college degree (e.g., a degree from a Junior College, a Community College, or 4-year College or University)? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If your answer is NO, you will not be eligible for this license. Application and license fees are not refundable.b. If the answer to a. is YES, check whichever of the following is applicable to you:  FORMCHECKBOX (1) I received a degree from a 4-year College or University, with a major in the schools mortuary science program, and the program is accredited by the American Board of Funeral Science Education (ABFSE).  FORMCHECKBOX (2) I received a degree from a 2-year Junior or Community College (or other 2-year college degree institution), with a major in the schools mortuary science program, and the program is accredited by the American Board of Funeral Science Education (ABFSE).  FORMCHECKBOX (3) I have a 2-year or 4-year college degree, but did not major in mortuary science; however, I have completed a course in mortuary science in a school that is accredited by the American Board of Funeral Science Education (ABFSE), and the course covered the following subjects: theory and practice of embalming, restorative art, pathology, anatomy, microbiology, chemistry, hygiene, and public health and sanitation.  FORMCHECKBOX (4) I have a 2-year or 4-year college degree, but did not major in mortuary science; however, I have completed a course in mortuary science in a school that is not accredited by the American Board of Funeral Science Education (ABFSE), and the course covered the following subjects: theory and practice of embalming, restorative art, pathology, anatomy, microbiology, chemistry, hygiene, and public health and sanitation. c. Provide the following information about the 2-year or 4-year college from which you have a degree. (1) Name of College or University:  FORMTEXT       (2) Address of School Registrar (street, city, state, zip):  FORMTEXT       (3) Name of Degree (e.g., Associate in Science):  FORMTEXT       (4) Name of Major:  FORMTEXT       (5) Dates of attendance: From (month & year):  FORMTEXT      / FORMTEXT      / FORMTEXT       To (month & year):  FORMTEXT      / FORMTEXT      / FORMTEXT       (6) Date of graduation:  FORMTEXT      / FORMTEXT      / FORMTEXT       d. If your answer to b. was (3) or (4), provide the following: (1) Name of school that conducted the mortuary science course:  FORMTEXT       (2) Address of school that conducted the course (street, city, state, zip):  FORMTEXT       (3) Month and year you began the course:  FORMTEXT      / FORMTEXT      / FORMTEXT       Month and year you completed the course:  FORMTEXT      / FORMTEXT      / FORMTEXT       e. Attach proof of graduation and course completion. (1) Attach to this application a certified true copy of your college transcript as issued by the school, showing all courses taken and date of graduation. (2) If you checked (3) or (4) in response to b., then regarding the mortuary science course you completed, attach a certificate of course completion or similar document, issued by the school that conducted the course and on that schools letterhead or form. f. Non-ABFSE Courses. If your answer to b. was (4), you must complete the Mortuary Science Course Information Form and attach it to this application when submitting same. That form may be obtained on the website of the Division of Funeral, Cemetery & Consumer Services, or you may request the form by letter directed to the Division office at the address shown at the top of this form.g. Have you completed a course on communicable diseases? YES  FORMCHECKBOX  NO  FORMCHECKBOX  (1) Was the course at least 2 hours long? YES  FORMCHECKBOX  NO  FORMCHECKBOX  (2) Was the course approved by the Division of Funeral, Cemetery and Consumer Services? (ask the entity that conducted the course) YES  FORMCHECKBOX  NO  FORMCHECKBOX  (3) Name of school or entity that conducted or sponsored the course:  FORMTEXT       (4) Where was the course held (e.g., Marriott Hotel, International Drive, Orlando):  FORMTEXT       (5) Date you took the course:  FORMTEXT      / FORMTEXT      / FORMTEXT       (6) Attach a certificate of attendance or other documentary evidence of having taken the course (must be issued by the entity that sponsored or conducted the course). Section 8. ADVERSE LICENSING HISTORY QUESTIONSAs used in this Section, you refers to applicant; deathcare industry license refers to any licensure as an embalmer, funeral director, direct disposer, funeral establishment, direct disposal establishment, centralized embalming facility, cinerator facility, removal service, refrigeration service, cemetery, monument establishment, or preneed sales business.(a) Have you ever had any deathcare industry license revoked, suspended, fined, reprimanded, or otherwise disciplined, by any regulatory authority in Florida or any other state or jurisdiction? YES  FORMCHECKBOX  NO  FORMCHECKBOX  (b) Have you ever had any application for a deathcare industry license denied for any reason by any regulatory authority in Florida or any other state or jurisdiction? YES  FORMCHECKBOX  NO  FORMCHECKBOX  (c) Have you ever voluntarily relinquished or surrendered a deathcare industry license while under investigation, or after initiation of a disciplinary proceeding against you or the license? YES  FORMCHECKBOX  NO  FORMCHECKBOX  (d) Are you currently to your knowledge under investigation by any regulatory or law enforcement authority in Florida or any other state or jurisdiction in regard to alleged misconduct or incompetency in the performance of work under a deathcare industry license? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If the answer to any of the questions in this Section is YES, you must fill out and submit with this application, an Adverse Licensing Action History Form. You must disclose on that form details of each adverse licensing action and pending investigation that required a YES answer to any of the questions in this Section of this application. This form may be obtained from the website of the Division of Funeral, Cemetery & Consumer Services, or it may be requested by letter directed to the Division office at the address shown at the top of this form.Section 9. CRIMINAL HISTORY QUESTIONSHave you, the applicant herein, ever plead guilty, been convicted, or entered a plea in the nature of no contest, regardless of whether adjudication was entered or withheld by the court in which the case was prosecuted, in the courts of Florida or another state or the United States or a foreign country, regarding any crime indicated below: 1. Any felony or misdemeanor, no matter when committed, which was directly or indirectly related to or involving any aspect of the practice or business of embalming, funeral directing, direct disposition, cremation, funeral or cemetery preneed sales, funeral establishment operations, cemetery operations, or cemetery monument or marker sales or installation. YES  FORMCHECKBOX  NO  FORMCHECKBOX  2. Any other felony not already disclosed under subparagraph 1. Immediately above, which was committed within the 20 years immediately preceding the date you submit this application. YES  FORMCHECKBOX  NO  FORMCHECKBOX  3. Any other misdemeanor not already disclosed under subparagraph 1. Above, which was committed within the 5 years immediately preceding the date you submit this application? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If you circled YES, you must fill out and submit with this application, a Criminal History Form. You must disclose on that form details of every criminal action against you that requires a YES answer to any of 1, 2, or 3 above. That form may be obtained on the website of the Division of Funeral, Cemetery & Consumer Services, or you may request the form by letter directed to the Division office at the address shown at the top of this form. Section 10. 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MISCELLANEOUS MATTERSa. Do you understand that after licensure, you have a continuing duty under state law [s. 497.146, Florida Statutes], to notify this Division within 30 days of any change in your mailing address? YES  FORMCHECKBOX  NO  FORMCHECKBOX  (A Change of Address or Contact Data form for individuals and entities may be found on the Division website)b. Do you understand that as part of this application, you must submit your fingerprints for a criminal background check? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Instructions concerning how and where to submit fingerprints may be reviewed and printed from the website of the Division of Funeral, Cemetery & Consumer Services, as follows: go to the website of the Department of Financial Services ( HYPERLINK "http://www.myfloridacfo.com" www.myfloridacfo.com), click on FLDFS Divisions and Offices, click on Funeral and Cemetery Services. c. Do you understand that you must take and pass the Florida Law & Rules examination with a score of at least 75% as a prerequisite to issuance of the license for which you are applying? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Your application is not complete until the Division receives an official report of your score on the Florida Law and Rules examination. The Florida Board of Funeral, Cemetery and Consumer Services will review this application and if it determines you meet all applicable criteria, it will approve you to sit for the Florida Law and Rules examination. You will be promptly notified of the Boards decision. If approved to sit for the Florida Law and Rules exam, you may schedule an examination time, date and place convenient to you. The exam is given daily at approximately 20 locations around Florida.d. Applicant may attach to this application one or more additional pages to explain any answer herein, or provide additional information the applicant desires the Division and Board to consider regarding this application. Are you attaching any such additional pages? YES  FORMCHECKBOX  NO  FORMCHECKBOX If yes, how many pages:  FORMTEXT      Section 12. APPLICANT S CERTIFICATION & SIGNATURE Under penalties of perjury, I, the applicant or applicant s authorized signatory, do hereby declare that I have read the foregoing application and all attachments, and the facts stated in it are true and correct. I declare that I have or will prior to commencing operations under this license comply with all requirements under Chapter 497, Florida Statutes, relating to the license for which I have applied. I hereby authorize any court, law enforcement agency, or licensing authority to release or make available to the Division of Funeral, Cemetery & Consumer Services in the Florida Department of Financial Services, and to the Florida Board of Funeral, Cemetery, and Consumer Services, any and all information in their files concerning me. _____________________________________ __________________________ Signature of Applicant Date Signed _____________________________________ Name and Title Mail completed application with all attachments, and required fees to: Division of Funeral, Cemetery & Consumer Services Revenue Processing P.O. Box 6100 Tallahassee, FL 32314-6100 Section 13. SOCIAL SECURITY NUMBEREnter Applicant s Social Security Number:  FORMTEXT       Purpose and Use: The collection of social security numbers on applications for licensure under Chapter 497 is expr*,@򹮝}g靑Sg&jKhhCJU]aJ+jhhCJU]aJmHnHu&jJhhCJU]aJhhCJ]aJ jhhCJU]aJh}6CJ]aJhh}CJ]aJ%jhCJU]aJmHnHu j#JhCJU]aJhCJ]aJjhCJU]aJ@BDNPRTVXd¹mUmm=m/jMhdhdB*CJU\aJph/j8MhdhdB*CJU\aJph)jhdhdB*CJU\aJph hdhdB*CJ\aJph h}5CJh}CJaJ h1\kCJ h}CJh}5CJ\aJh}CJ\aJhhCJ]aJ%jhCJU]aJmHnHujhCJU]aJ jKhCJU]aJTV$IfmkdK$$Ifl4L$D% t0D%644 laf4yt0sd<<$7$8$H$If $<<$Ifa$kdL$$Ifl4L$D%  t 0D%644 laf4p yt/01̻vo`UE`:h}0J6CJ]jOh}6CJU]h}0J6CJ]jh}0J6CJU] h}CJ\/j%OhdhdB*CJU\aJph/jNhdhdB*CJU\aJph)jhdhdB*CJU\aJph hdhdB*CJ\aJph h}5CJh}6CJ]aJh}6B*CJ]aJphh}6CJ]h}CJ\aJ01Yx <<$If $<<$Ifa$okd N$$Ifl4L$D% t0D%644 laf4yt.9VXYZ,-.34BCDE³qld³M,j|Rhd5B*CJU\aJphh}6\] h}5,jwQhd5B*CJU\aJph,jQhd5B*CJU\aJph&jhd5B*CJU\aJphhd5B*CJ\aJph h}\h}6CJ] h}CJ\ h}CJh}6>*CJ]h}6CJ]jh}0J6CJU]YZE <<$IfokdrP$$Ifl4L$D% t0D%644 laf4ytx <<$Ifgdd <<$IfokdQ$$Ifl4L$D% t0D%644 laf4yt|~1  = M O Q    ~vrvlv]lv~vlrNh}5CJOJQJ\^Jh}5CJOJQJ^JaJ h}CJh}h}CJaJh}5CJaJh}6CJ]jhdU\mHnHujdShdU\ hd\jhdU\ h\ h}\&jhd5B*CJU\aJph,jRhd5B*CJU\aJphhd5B*CJ\aJph| $$7$8$H$Ifa$okdS$$Ifl4L$D% t0D%644 laf4yt|~/01  - M O zzzzzzzzzzzzz $7$8$H$IfzkdkT$$IflL$D%  t 0D%644 lap ytO P Q      J L N zpjz[$7$8$H$If^$If $If^$If $$Ifa$jkdU$$IflL$D% t0D%644 layt $7$8$H$If      J P            >  ,f.h.n.o.q.r.ʾ}ymdbdWSKGKh8jh8Uh}h,"hYCJaJUh6CJaJh56>*CJaJhjhU-jh6CJOJQJU^JmHnHujVh6CJUjh6CJU h6CJh,"hY5CJaJhY5CJaJh}CJaJ h}CJh}PJaJ h}aJ h}5CJOJPJQJ\^JN P   $$Ifa$gd48jkdU$$IflL$D% t0D%644 layt    > g.yppp $Ifgd $$Ifa$gdzkd-V$$IflL$D%  t 0D%644 lap ytessly authorized by s. 497.141(2), Florida Statutes. Social security numbers collected on applications will be used by the Department of Financial Services and the Board of Funeral, Cemetery and Consumer Services as follows: identification of applicants; obtaining background checks on applicants; obtaining information from authorities in other states; investigation of applicants and licensees concerning asserted violations of applicable law or rules; enforcement of child support obligations. The social security number may also be used for any other purpose required or authorized by federal or Florida Law.     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