Fillable Application for a Certicate of Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for a Certicate of Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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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 a Certicate of Registration
All questions must be answered by the applicant except where indicated.
Pursuant to N.J.S.A. 45:7-55, application is hereby made to register the establishment referred to below, and for a certicate of
registration to maintain and operate the facility for the period ___________________________ through December 31, 20 ___.
1a. Exact name under which the establishment is conducted and the address:
____________________________________________________________________________________________________
New name
____________________________________________________________________________________________________
Street address
____________________________________________________________________________________________________
City County ZIP code
__________________________ ____________________________ ________________________________________
Telephone number (include area code) License Number E-mail address
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 establishment’s name above is a corporation or trade name, please list the State or Federal Tax Identication number:
Number ______________________________________________
2a. Provide the name and license number of the licensed manager or licensee-in-charge of this establishment:
_____________________________________________________ ___________________________________
Manager/Licensee License number
New installation inspection fee: $150.00
Certicate of Registration: 700.00
$850.00
Change of manager fee: $35.00
First Year / Even
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 a Certicate of Registration (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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