Form Bol-Mor Fe - Application For Funeral Establishment License - State Of Idaho - 2010 Page 2
Download a blank fillable Form Bol-Mor Fe - Application For Funeral Establishment License - State Of Idaho - 2010 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Bol-Mor Fe - Application For Funeral Establishment License - State Of Idaho - 2010 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2APPLICATION FOR FUNERAL ESTABLISHMENT LICENSE (cont.)
10. Does this application represent a change in location of your funeral establishment?
[ ] YES
[ ] NO
(If YES, give name _______________________________________________________________ License #_____________
and establishment address_________________________________________________________________________________
11. Have you previously owned a funeral establishment in Idaho or elsewhere?
[ ] YES
[ ] NO
(If YES, give name _______________________________________________________________ License #_____________
and establishment address________________________________________________________________________________
12. Have you ever had a license, certification, or registration denied, revoked or suspended?
[ ] YES
[ ]NO
(If yes, please attach a detailed statement, including a copy of the charges and the final order.)
13. Have you ever been convicted of any State or Federal felony?
[ ] YES
[ ]NO
(If yes, please attach a detailed statement, including a summary of the charges, the final order, any probation or parole
documentation, and any other relevant information.)
AFFIDAVIT
I hereby certify under penalty of perjury that the responses provided above and that all attached documentations are true and accurate to the
best of my knowledge and belief and that I am of good moral character and temperate habits.
I further certify that I am familiar with all city, county, and state planning and zoning regulations affecting the facility and location listed
above and that I assume all responsibility for their compliance.
I hereby authorize and direct any person, agency, firm, or other entity to release, upon the request of the Bureau of Occupational Licenses or
it’s authorized representative, any information, communication, report, record, statement, recommendation, or disclosure that may have
bearing on my eligibility for or maintenance of the license for which I am applying. I understand that by signing this form I am authorizing
the release of information about me that may otherwise be protected or confidential. If signing as an authorized agent, I certify that I am
authorized to sign this application on behalf of the licensee.
__________________________________________________
Signature of Owner(s) or Agent(s)
State of Idaho, County of ______________________, ss.
Subscribed and sworn before me this _____ day of ______________, 20 ____.
___________________________________________
(seal)
Notary Public official signature
my commission expires________________________
RESIDENT MORTICIAN AFFIDAVIT
I hereby certify under penalty of perjury that I am a resident of the state of Idaho and that I am in the employ or service of the
above noted funeral establishment at the location noted on a full-time basis.
I hereby authorize and direct any person, agency, firm, or other entity to release, upon the request of the Bureau of
Occupational Licenses or it’s authorized representative, any information, communication, report, record, statement,
recommendation, or disclosure that may have bearing on my eligibility for or maintenance of the license for which I am
applying. I understand that by signing this form I am authorizing the release of information about me that may otherwise be
protected or confidential.
__________________________________________________
Signature of mortician
State of Idaho, County of ______________________, ss.
Subscribed and sworn before me this _____ day of ______________, 20 ____.
____________________________________________
(seal)
Notary Public official signature
my commission expires_________________________
BOL-MOR FE – revised 7/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Bol-mor-1 - License Renewal Application - Bureau Of Occupational Licenses, State Of Idaho
Legal
Application For Original Establishment License Form - Idaho Bureau Of Occupational Licenses
Business
Related Categories
Parent category: Legal