Form Bol-Mor Coa - Application For Certificate Of Authority
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1my commission expires ___________________________
STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
700 WEST STATE STREET, PO BOX 83720
Boise, Idaho 83720-0063
(208) 334-3233
APPLICATION FOR CERTIFICATE OF AUTHORITY
An application fee of $100.00 and a license fee of $50.00 must be submitted with this application.
I hereby make application for a Certificate of Authority in the State of Idaho under the provisions of § 54-1129 & § 54-1132, Idaho
Code, and provide the following:
1. Business Name: _________________________________________________________________License # ________________
2. Business Owner _________________________________________________________________________________________
3. Business address_________________________________________________________________________________________
Street/PO Box
City
State
Zip
4. Business phone _(____)____________ Fax _(____)______________ E-mail ____________________________________
(The above phone number is public record)
5. Name of Agent _________________________________________________________________ License # ________________
(The individual agent's name must be provided. The individual agent must respond to the items below & sign the application.)
6. Date of Birth _____/_____/_____ Place of Birth__________________________ Social Security No. ______/______/______
mm/dd/yyyy
7. Are you currently or have you ever been licensed as a mortician or funeral director in any state?
[ ] Yes
[ ] No
(If yes, please attach a photocopy of your current license.)
8. Have you ever had any 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.)
9. 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.)
10. Please attach a copy of each form of contract you will use.
(Each contract form must comply with the Form and content and priced disclosure requirements of 54-1133 Idaho Code.)
10. Please attach an unmounted passport style photograph of yourself, taken within 30 days of this application.
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 have
reviewed and will comply with the Idaho Laws and Rules governing the sale of prearrangement sales contracts.
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 business owner or authorized agent (if other than owner)
State of _______________, County of ___________________, ss
Subscribed and sworn before me this _____ day of ______________________________, 20 ___
____________________________________________________
(seal)
Notary Public official signature
BOL-MOR COA - revised 04/2010
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