Form Bol-Mor-M-1 - Application For Mortician Licensure - 2010 Page 2
Download a blank fillable Form Bol-Mor-M-1 - Application For Mortician Licensure - 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-M-1 - Application For Mortician Licensure - 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
2
3STATE OF IDAHO
IDAHO STATE BOARD OF MORTICIANS
APPLICATION FOR MORTICIAN LICENSURE
An application fee of $100.00 and an $85.00 license fee must be submitted with this application.
I hereby submit my qualifications and make application for a license or permit to practice as a Mortician in the State of Idaho under
the provisions of Title 54, Chapter 11, Idaho Code, as amended and provide the following:
1. Full Name (Mr., Mrs., or Ms.) ______________________________________________________________________________
2. Mailing address__________________________________________________________________________________________
Street/PO Box
City
State
Zip
3. Date of Birth _______/_______/_______ Place of Birth_____________________ Social Security No. ______/______/______
month
day
year
(Proof of being 21 years of age must be attached – i.e. a copy of birth certificate, passport, military ID, or valid driver’s license).
4. Business phone _(____)_______________ Fax _(____)__________________ E-mail _______________________________
(The above phone number is public record)
5. Are you currently or have you ever been licensed as a mortician or funeral director in any state?
[ ] Yes
[ ] No
(If yes, this office must receive certified documentation of said licensure directly from the licensing entity. If you are licensed in
Idaho, please attach a photocopy of your current license.)
6. Have you practiced as a licensed resident trainee in Idaho for not less than 12 months?
[ ] Yes
[ ] No
(If you are not currently licensed in another state, documentation verifying compliance with § 54-1109.05., Idaho Code & Rule 250
must be on file with the Board. If No to both 5 & 6, the Resident Trainee application must be submitted instead of this application.)
7. Have you completed the college educational requirements outlined in § 54-1109.03, Idaho Code? [ ] Yes
[ ] No
(If Yes, this office must receive official certified transcripts directly from the university/college registrar.)
8. Have you completed the embalming school educational requirements outlined in § 54-1109.04, Idaho Code?
(If Yes, this office must receive official certified transcripts directly from the university/college registrar.)
[ ] Yes
[ ] No
9. 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.)
10. 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 have
reviewed and will comply with the Idaho Laws and Rules governing my practice.
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 applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 20 _____.
______________________________________________________
(seal)
Notary Public official signature
my commission expires___________________________________
(continued)
BOL-MOR-1 - revised 7/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal