Fillable Application for Funeral Home Registration Name Change (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for Funeral Home Registration Name Change (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Application for Funeral Home Registration Name Change (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 2 pages long and contains:

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  • 11 check-boxes
  • 60 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Mortuary Science of New Jersey
124 Halsey Street, 6th Floor, P.O. Box 45009
Newark, New Jersey 07101
(973) 504-6425
Application for Funeral Home Registration Name Change
All questions must be answered by the applicant except where indicated.
New rm name registration fee: $40.00
Please print clearly. Date __________________________________
Application is hereby made to register a new establishment name for:
____________________________________________________________ License No. ____________________________
Old name
1a. New name under which the establishment is conducted and the address:
____________________________________________________________________________________________
New name
____________________________________________________________________________________________
Street address
____________________________________________________________________________________________
City County ZIP code
___________________________________ E-mail address: ________________________________________
Telephone number (include area code)
b. Type of ownership: (Check the one that applies.)
Individual Partnership
Individual-Trade name Partnership-Trade name
Corporation Estate
Corporation-Fictitious name Limited Liability Company
Other (Explain)
c. List below the name and address of every individual in whom ownership is vested (corporations excluded).
Fullnameofowner Homeaddress
1. _________________________________________
2. _________________________________________
3. _________________________________________
d. If the new name above is a corporation or trade name, please list the State or Federal Tax Identication number:
Number ___________________________________
For Ofce Use Only
PermitNo. ________________
Datereceived________________
2a. Provide the name and license number of the licensed manager or licensee-in-charge of this establishment:
_____________________________________________________ ___________________________________
Manager/Licensee License number
b. If you are managing more than one funeral home, list below the name, license number and address of each.
Funeralhomename Funeralhomeaddress
1. ____________________________________________
License No. _________________________________
2. ____________________________________________
License No. _________________________________
3. ____________________________________________
License No. _________________________________
c. Provide the name of every licensed employee.
__________________________________________ __________________________________________
__________________________________________ __________________________________________
__________________________________________ __________________________________________
d. Provide the name of every trainee and unlicensed employee and the hours each of them work per week.
Name Homeaddress Hoursperweek
___________________________________ _________________________________________________ _____________
___________________________________ _________________________________________________ _____________
___________________________________ _________________________________________________ _____________
___________________________________ _________________________________________________ _____________
To be answered by corporate applicants only.
3a. Exact name of the corporation _____________________________________________________________________________
b. Name and address of the registered agent of the corporation.
_______________________________________________________________________________________________________
Name Street address City State ZIP code
c. Date of incorporation __________________________________
d. Names of all ofcers and, in addition, the owners of 5% or more of stock:
Name Percentage
President _______________________________________________________________ _________________
Vice President ___________________________________________________________ _________________
Secretary _______________________________________________________________ _________________
Treasurer _______________________________________________________________ _________________
Other __________________________________________________________________ _________________
e. Has there been a change in the list of corporate ofcers in the past year? Yes No
f. State the amount of common stock issued ___________________________________________________________________
g. State the amount of preferred stock issued ___________________________________________________________________
The answers and statements made in this form are true and correct to the best of my knowledge and belief. I agree to display the
Certicate of Registration and understand that the Certicate is not transferrable. I am familiar with the provisions of Chapter
184, Law of 1960, and the Rules and Regulations of the Board.
_________________________________________________
Signature of licensee/manager-in-charge of establishment
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Application for Funeral Home Registration Name Change (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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