Form Dfs-n1-1743 - Change Of Funeral Director/direct Disposer In Charge - 2012

DEPARTMENT OF FINANCIAL SERVICES
Division of Funeral, Cemetery & Consumer Services
200 East Gaines Street
Tallahassee, FL 32399- 0361
Change of Funeral Director/Direct Disposer in Charge
Funeral Establishments or Direct Disposal Establishments use this form to notify the Division of Funeral,
Cemetery & Consumer Services of changes to their Funeral Director/Direct Disposer in Charge. There is
no fee. Mail this form to the Division at the address indicated in the letterhead.
Section 1. Identifying Information
Please provide all data requested in this Section, so that we can accurately identify the record to be updated.
Entity name as licensed:
FEIN
Existing licensees only -- if you are an existing licensee, enter your license number in this block:
Establishment License Number:____________
License applicants only -- if you are an applicant for license, indicate what month and year you submitted
your application and what type of license was applied for:
Month _____ Year _____ Type of License ___________________________
Section 2. Address
Preferred Mailing Address:
Street ___________________________________________________________________
City: _______________________________ State ____ Zip _____ Country ____________
Phone number
Email address (e.g., )
Area code_____ Phone # _____- _________
Section 3: Funeral Director/Direct Disposer In Charge
Current Named Funeral Director/Direct Disposer In Charge:
Name____________________________________
License Number:________________
License Type (circle one): DD EM FD FD/EM
Change to new Funeral Director/Direct Disposer In Charge:
Name____________________________________
License Number:________________
License Type (circle one): DD EM FD FD/EM
Date Effective: _____/_____/______
Section 4: Signature
I, the licensee or applicant identified above, hereby request the Division of Funeral, Cemetery & Consumer
Services to conform the data in their records concerning the funeral director/direct disposer to the information
entered above.
___________________________________
________________________
Signature
Date signed
Form DFS-N1-1743; Change of Funeral Director/Direct Disposer in Charge
1 of 1
(Rev 2/12); 69K-1.001
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