Form Bol-Mor Fe - Application For Funeral Establishment License - State Of Idaho - 2010
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2STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
700 West State Street
PO Box 83720
Boise, Idaho 83720-0063
APPLICATION FOR FUNERAL ESTABLISHMENT LICENSE
INSTRUCTIONS
Please complete this form by printing or typing the requested information and attaching any requested documentation. Your
signature must be notarized and the appropriate fee must be attached. Submit the completed form to the address noted above.
Applications that are not complete or do not provide the requested information will be delayed. Questions regarding this
application or the requirements for licensure may be addressed to the addresses or numbers above.
NOTE: All funeral establishments must be inspected by the Idaho Board of Mortician Examiners prior to the issuance
of an establishment license. Operation prior to obtaining a valid license is unlawful and may result in criminal
prosecution and denial of licensure.
Application Checklist: A funeral service establishment license requires the following:
___Completed application and fees.
___A licensed Idaho Mortician who is a resident of Idaho on staff, full time.
___A specific location and name for the establishment.
___Must contain an operating room and equipment for embalming, a display room for merchandise, a chapel, and a
viewing/visitation room.
___Upon receipt of all documents, a walk-through inspection of the establishment is arranged and upon passing the inspection,
the license is issued.
NOTE: Prior to walk-through applicants must be familiar with all city, county, and state planning and zoning regulations affecting the
facility and location being applied for and assume all responsibility for compliance.
Please keep a copy of this application for your records.
An application fee of $100.00 & an original license fee of $125.00 must be submitted with this application.
I hereby make application for a funeral establishment license in the State of Idaho under the provisions of Title 54, Chapter 11,
Idaho Code, and provide the following:
1. Name of funeral establishment________________________________________________________________________
2. Location Address___________________________________________________________________________________
street
city
zip
3. Mailing Address ____________________________________________________________________________________
street/route/box
city
zip
4. Business phone _(____)______________ Fax _(____)______________
E-mail ______________________________
(The above phone number is public record)
5. Owner(s) Name_______________________________________________________________ License # _____________
(Please attach a photocopy of your current license.)
6. Please check the appropriate ownership designation: [ ] Individual [ ] Corporation
[ ] Partnership [ ] Other
If Other, please describe:__________________________________________________________________________________
(Please attach a list of all principle persons if ownership is other than “Individual”)
7. Employer Identification Number ____________________ or Social Security Number _____/____/_____
8. Name of full time resident mortician:________________________________________________ License # __________
(Idaho Law requires each establishment to employ a full time licensed resident mortician)
9. Has a funeral establishment previously existed at this location?
[ ] YES
[ ] NO
If YES, give previous name ___________________________________________________________ License #___________
and owner name_________________________________________________________________________________________
(If YES and the license is current, said license must be signed by the previous owner and attached.)
(CONTINUED)
BOL-MOR FE – revised 7/10
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