Fillable APPLICATION TO REPORT DESIGNATION OR CHANGE OF CEMETERY (California)

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APPLICATION TO REPORT DESIGNATION OR CHANGE OF CEMETERY (California)

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APPLICATION TO REPORT DESIGNATION OR CHANGE OF CEMETERY OR CREMATORY
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
MANAGER AND/OR REQUEST APPROVAL TO SHARE
Designate a Crematory Manager $50.00 Fee Requesting Approval to Share a Crematory Manager $50.00 Fee
Designate a Cemetery Manager $50.00 Fee
Requesting Approval to Share a Cemetery Manager $50.00 Fee
(submit a written statement demonstrating two years
experience in the cemetery business.)
SECTION A: APPLICANT INFORMATION
Business Name License Type and Number
Address City State
CA
Zip Code
Contact Person Fax Number
( )
Telephone Number
( )
SECTION B: MANAGER INFORMATION (Cemetery Managers must submit a written statement demonstrating two years experience.)
Name of Previous Manager License Number Date of Disassociation
Name of New Manager License Type/Number Expiration Date Date of Association
Under this mangers license is this manager designated at any
other Cemetery/Cematory?
No Proceed to section D Yes Complete section C
SECTION C: APPROVAL TO SHARE A MANAGER
(The Cemetery or Crematory must be under common ownership, have a designated main office, and be within 60 miles of the main office.)
Designated Main Office License Number Miles From Establishment in
Section A?
Address of Main Office City State
CA
Zip Code
Designated Manager is also the
Designated Manager at the following
licensed Cemeteries/Crematories
under this CEM/CRM license.
COA/CR# (Circle One) COA/CR# (Circle One) COA/CR# (Circle One) COA/CR# (Circle One) COA/CR# (Circle One)
Type of Ownership
Corporation Partnership
(Crematory only)
Sole Owner
(Crematory only)
Name(s) of Corporation, Partners, or Sole Owner
SECTION D: OWNER, PARTNER, OR CORPORATE OFFICER CERTIFICATION
(Must be signed by the owner, if a Sole Owner; a Partner, if a Partnership; a Corporate Officer if a Corporation.)
I understand that this establishment must employ a licensed manager at all times, and any change of the designated manager will be
reported to the Bureau within 10 days. I certify under penalty of perjury under the laws of the State of California that all statements
furnished in connection with this application are true and accurate.
Signature Print Name Date
FOR BUREAU USE ONLY
Date Cashiered Amount Cashiered ATS Number Receipt Number
Date Approved Common Ownership
Checked
Within 60 Miles Related License CR/COA License
Ordered
Duplicate Manager
License Ordered
REV (08/13) Cemetery and Funeral Bureau – www.cfb.ca.gov Page 1 of 1
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information
The Cemetery and Funeral Bureau of the Department of Consumer Affairs collects the
personal information requested on this form as authorized by Business and Professions
Code Sections 30, 144, 7617.1, 7618, 7619, 7620, 7628, 7642, 7643, 7661, 7662, 7665,
7667, 9650, 9650.2, 9650.3, 9700, 9701, 9702.1, 9704, 9715, 9715.1, 9716, 9723,
9723.1, 9741, 9745, 9746, 9781, 9787.3 and the Information Practices Act. The
Cemetery and Funeral Bureau uses this information principally to identify and evaluate
applicants for licensure, issue and renew licenses, and enforce licensing standards set by
law and regulation.
Mandatory Submission
Submission of the requested information is mandatory unless otherwise noted on the
form. The Cemetery and Funeral Bureau cannot consider your application for licensure or
renewal unless you provide all of the requested information.
Access to Personal Information
You may review the records maintained by the Cemetery and Funeral Bureau that
contain your personal information, as permitted by the Information Practices Act. See
below for contact information.
Possible Disclosure of Personal Information
We make every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
In response to a Public Records Act request (Government Code Section 6250 and
following), as allowed by the Information Practices Act (Civil Code Section 1798 and
following);
To another government agency as required by State or Federal law; or,
In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information
For questions about this notice or access to your records, you may contact the Custodian
of Records, Cemetery and Funeral Bureau at 1625 North Market Boulevard, Suite S-208,
Sacramento, CA 95834, by phone at (916) 574-7870, or by e-mail at
emailcfb@dca.ca.gov. For questions about the Department’s Privacy Policy, you may
contact the Department of Consumer Affairs at 1625 North Market Boulevard,
Sacramento, CA 95834, by phone at (800) 952-5210, or by e-mail at dca@dca.ca.gov.
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APPLICATION TO REPORT DESIGNATION OR CHANGE OF CEMETERY (California)

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Completed 8 June 2021

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