STATE OF NEVADA
FUNERAL AND CEMETERY SERVICES BOARD
3740 Lakeside Drive, Suite 201, Reno, Nevada 89509
Phone (775) 825-5535 * Fax (775) 507-4102
Email: firstname.lastname@example.org * Website: http://funeral.nv.gov/
Nevada Funeral Board Criminal History Form Rev. 8/13/2019
This form is used in conjunction with various license application forms to provide details concerning criminal history.
This form must be completed if applicant for any license has a criminal history. Each “item” on this form should indicate
a separate criminal prosecution in which you plead guilty, were found guilty, or plead nolo contendere (no contest). You
will need to fill out a copy of this form for each prosecution (copy as needed). A copy of the police report and/or other
legal documents related to the criminal charge must be attached to this criminal history form for each crime
Item (Police report and or other legal documents related to the criminal charge must be attached)
Year charges were filed against you:
Date on which you pled guilty, found guilty or pled no contest:
☐ Category C, D or E Felony
Have all sanctions imposed been satisfied?
Have you attached the police report and/or legal documents related to the criminal
Do you have any other criminal record items to disclose?
If yes, each item requires another copy of this form.
I hereby declare under penalty of perjury, that all of the information supplied herein is to the best of my knowledge true,
accurate and complete and I have not withheld, misrepresented, or falsely stated any information contained herein.