Form 08-4071 - Change Of Supervisor Form - State Of Alaska Department Of Community And Economic Development

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MOR
STATE OF ALASKA
Date Stamp
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
MORTUARY SCIENCE SECTION
P.O. BOX 110806, JUNEAU, ALASKA 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
CHANGE OF SUPERVISOR FORM
Trainee: You must immediately notify the division, in writing, when you change supervisors.
Complete this form, including the notarization, return your current license for amendment
to show the new assignment, and pay the $5 fee. Make check or money order payable to
the State of Alaska. If you are not employed as a mortuary trainee and have no supervisor at
this time, write “unassigned” in the “current assignment” area. Your trainee permit will be
For Department Use Only
effective under the new supervisor when your completed form, fee, and returned license (permit)
are processed by the state. Supervision under the new sponsor and training time are not
Only Trainee of this
effective until approval by the state. (12 AAC 50.100(c))
Sponsor
Date Entered
License #
Mortuary Trainee Name
New License Sent
Initials
Mailing Address
City
State
ZIP Code
PREVIOUS ASSIGNMENT
Name of Funeral Establishment – where training was conducted
Funeral Est. License #
Mailing Address
City
State
ZIP Code
License Expiration Date
Name of Previous Sponsoring Supervisor
License #
Date Supervision Ended
CURRENT ASSIGNMENT
Name of Funeral Establishment – where training is to be conducted
Funeral Est. License #
Mailing Address
City
State
ZIP Code
License Expiration Date
Name of New Sponsoring Supervisor
License #
I certify that the information in this document is true and correct to the best of my knowledge.
Signature of Mortuary Trainee
Date
SUBSCRIBED AND SWORN TO before me on
(date).
Signature of Supervisor
Date
Notary Public, State of
My Commission Expires
08-4071 (New 8/00)

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