Form Bol-Mor-M-1 - Application For Mortician Licensure - 2010 Page 3
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1
2
3APPLICATION FOR MORTICIAN LICENSURE
ADDENDUM I
A. CHARACTER REFERENCES: Please provide the names and addresses and phone numbers of
three character references below.
_______________________________
_________________________________
_________________________________
_______________________________
_________________________________
_________________________________
_______________________________
_________________________________
_________________________________
B. PRACTICAL WORK EXPERIENCE: List your work experience including employers names, addresses, phone numbers
and dates of practice.
NAME OF BUSINESS _________________________________ EMPLOYERS NAME _________________________________
ADDRESS of BUSINESS ___________________________________________________ PHONE NO. _____________________
DATES of PRACTICE _______________________________ TO ________________________________
NAME OF BUSINESS _________________________________ EMPLOYERS NAME _________________________________
ADDRESS of BUSINESS ___________________________________________________ PHONE NO. _____________________
DATES of PRACTICE _______________________________ TO ________________________________
NAME OF BUSINESS _________________________________ EMPLOYERS NAME _________________________________
ADDRESS of BUSINESS ___________________________________________________ PHONE NO. _____________________
DATES of PRACTICE _______________________________ TO ________________________________
If more space is needed, attach a separate sheet of paper
_______________________________________________________________________________________________________
C. PHOTOGRAPH: Attach below an original passport photograph of yourself taken within the preceding 3
months.
HEIGHT
_____________
WEIGHT
_____________
(attach photograph here)
EYE COLOR
_____________
HAIR COLOR _____________
OTHER DISTINGUISHING FEATURES _____________
__________________________________________________
__________________________________________________
__________________________________________________
BOL-MOR-1 - revised 7/10
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