Texas Funeral Service Commission Commercial Embalming Facility Application Form Page 2

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Texas Funeral Service Commission
Commercial Embalming Facility Application
Name of Facility _________________________________________________________
Physical Address__________________________________________________________
(street)
(city)
(zip)
Mailing address (if different from above) ______________________________________
________________________________________________________________________
Telephone Number ________________________ Fax Number____________________
Email Address: ___________________________________________________________
Please check all that apply:
New Establishment
Name Change *
Ownership Change *
Physical Location Change *
* Provide the name and license number of existing establishment for changes starred above:
______________________________________________________________________________
______________________________________________________________________________
Is this establishment on cemetery property?
Yes_________ No _________
Is this establishment on tax exempt property?
Yes_________ No _________
Is there a facility in the service area, county or city that bears a similar name?
No
Yes – Name:__________________________________________________________
TYPE OF BUSINESS:
Sole ownership
Partnership
Corporation (MUST SUBMIT Franchise Tax Addendum)
List names and addresses of the sole owner, partners, or officers of the corporation (attach
additional sheet if necessary).
Name_________________________________________________________________________
Title __________________________________________________________________________
Address_______________________________________________________________________
Name_________________________________________________________________________
Title __________________________________________________________________________
Address_______________________________________________________________________
Name_________________________________________________________________________
Title __________________________________________________________________________
Address_______________________________________________________________________

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