Texas Funeral Service Commission Commercial Embalming Facility Application Form Page 4
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5TEXAS FUNERAL SERVICE COMMISSION
APPOINTMENT OF EMBALMER IN CHARGE
Establishment Name
License Number
Street Address
City
Zip
Embalmer Director in Charge
License Number
Expiration Date
_____________________________
Date Appointed
Are you currently serving as EIC/FDIC at any other location(s)? Yes____
No ____
Establishment Name(s)
Location(s)
Establishment License #
______________________________________________________________________________
As the Embalmer in Charge, I am responsible to the Commission for the legal and ethical
operation of this establishment and understand that I may be served with administrative
process when violations are alleged to have been committed by the funeral establishment. I
will notify the Commission in writing immediately if and when the relationship is
terminated. I certify to the correctness contained in this application.
______________________________________________
Embalmer in Charge
______________________________________________
Establishment Owner
Subscribed and sworn to me, the undersigned Notary Public of the State of Texas, on this the ____ day of _____________________,
________.
_______________________________
__________________________________
Notary Public
My Commission Expires
(seal)
Address
Toll Free: (888) 667-4881
Physical Address:
:
P. O. Box 12217
Tel: (512) 936-2474
333 Guadalupe Street
Capitol Station
Fax: (512) 479-5064
Suite 2-110
Austin, Texas 78711
website:
Austin, Texas 78701
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