Texas Funeral Service Commission Commercial Embalming Facility Application Form Page 3

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EMPLOYEE LISTING
Licensed personnel employed and active in this facility (attach additional sheet if necessary):
Name_________________________________License #_________________________
Name_________________________________License #_________________________
Name_________________________________License #_________________________
Name_________________________________License #_________________________
Name_________________________________License #_________________________
Non-licensed personnel employed and active in this facility (attach additional sheet if necessary):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
As the owner or officer of the commercial embalming facility:
I hereby consent to reasonable inspection of this facility and its records for compliance
with the Mortuary Laws of the State of Texas at such times as may be designated by the
Texas Funeral Service Commission.
I shall designate to the Commission an Embalmer in Charge, and such Embalmer in
Charge shall be directly responsible for the embalming of the licensed commercial
funeral establishment. Any change to the designation shall be given to the Commission
within 15 days.
I affirm that the statements and information contained in this application are true and
correct.
______________________________________________________________________________
Signature
Title
Before me, the undersigned, a notary public in and for the State of Texas, on this day personally
appeared_________________________________, who by me being placed under oath, disposes and says that
he/she is the ______________________ (title) of the ____________________________________________
(establishment).
Subscribed and sworn to before me this ________________day of _______________________ 20______.
____________________________________
(SEAL)
Notary Public in and for the State of Texas
My commission expires_______________

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