Fillable FUNERAL AND CEMETERY SERVICES BOARD Application and Instructions (State of Nevada, Department of Information Technology)

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FUNERAL AND CEMETERY SERVICES BOARD Application and Instructions (State of Nevada, Department of Information Technology)

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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: nvfuneralboard@fb.nv.gov * Website: http://funeral.nv.gov/
Nevada Funeral Board AE App Rev. 5/28/2020
Application and Instructions for
Apprentice Embalmer Certificate of Registration
Eligibility and Information
Any individual wishing to obtain a certificate of registration in the State of Nevada as an Apprentice Embalmer must be at
least 18 years of age, be of good moral character, complete this application and submit all required documentation with a
$375.00 application fee. Once the Board receives all required documentation, a background check will be completed, and
the application will be reviewed.
Required Documents
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Completed Application: Applications are required to be completed in full and must be signed. An incomplete
application will not be accepted and may be returned to the applicant. Omissions or fraudulent answers may
be grounds for denial of application.
Transcripts: Applicants for certification as an Apprentice Embalmer must submit verification of 60 semester
hours or 90 quarter hours at an accredited college or university (credits earned as part of the core mortuary
science program do not fulfill this requirement).
Nevada Business License: Individuals who are self-employed or working as independent contractors are
required to comply with Nevada business licensing requirements if applicable. Information is available through
the Secretary of State’s Office or www.nvsilverflume.gov.
Affidavits: Applicants for certification as an Apprentice Embalmer must submit an affidavit from his or her
preceptor that applicant shall enter upon his or her duties as soon as the certificate is granted.
Criminal History Form and/or Legal Reporting Form: These documents must be completed if applicant has a
criminal history to report or legal information to report. Form can be found on Board website or mailed upon
request.
Full Face Photograph of Applicant: Please submit a 2” x 2” full face passport photograph with application.
Fee: A non-refundable payment in the amount of $375 must be submitted at time of application. Acceptable
forms of payment include, check, money order or credit card and payable to the “Nevada Funeral and Cemetery
Services Board.”
Instructions for Completing Your Application
• Complete the Apprentice Embalmer Certificate of Registration application and, submit all required documents
including criminal history or legal reporting forms if required.
• Once all required information has been received by the Board, allow ten (10) days for processing the application.
When the application process is complete, if approved, the applicant will receive an approval letter with certificate.
• The application may need to be reviewed by the Board at the next Board meeting depending on information submitted
or obtained by the Board. If a review at a Board meeting is required, Applicant will be notified of the date, time and
location of the meeting if review at a Board meeting is required.
Mail, Email or Fax Completed Application with Fees to:
Nevada Funeral and Cemetery Services Board
3740 Lakeside Drive, Suite 201, Reno, NV 89509
(775) 825-5535 – Fax: (775) 507-4102
Email: nvfuneralboard@fb.nv.gov
CLEAR
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 2 of 7
Application and Instructions for Apprentice Embalmer Certificate of Registration
Nevada Funeral Board AE App Rev. 5/28/2020
Applicant Information
Full Legal Name:
Home Mailing Address: City: State: Zip:
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Personal E-mail Address:
Phone Number: Home Cell
Social Security Number: Date of Birth: Sex:
☐ Male ☐ Female
Citizenship:
☐
US Citizen
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Authorized to Work in the US Place of Birth:
List all prior names used by applicant:
Employment Information
Name of Employer:
Work Mailing Address: City: State: Zip:
Work E-mail Address:
Phone Number: ☐ Work ☐ Cell
Preferred Contact Information (all Board correspondence will be sent to selected):
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Home
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Work
Address History – Please list places of residence for the last 10 years – attach additional sheets if necessary
1. Current Physical Address: City: State: Zip:
Dates of Residence: From:
To:
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Own
☐
Rent
2. Prior Physical Address: City: State: Zip:
Dates of Residence: From:
To:
☐
Own
☐
Rent
3. Prior Physical Address: City: State: Zip:
Dates of Residence: From:
To:
☐
Own
☐
Rent
4. Prior Physical Address: City: State: Zip:
Dates of Residence: From:
To:
☐
Own
☐
Rent
5. Prior Physical Address: City: State: Zip:
Dates of Residence: From:
To:
☐
Own
☐
Rent
6. Prior Physical Address: City: State: Zip:
Dates of Residence: From:
To:
☐
Own
☐
Rent
7. Prior Physical Address:
City: State: Zip:
Dates of Residence: From:
To:
☐
Own
☐
Rent
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 3 of 7
Application and Instructions for Apprentice Embalmer Certificate of Registration
Nevada Funeral Board AE App Rev. 5/28/2020
Professional Employment History (5 years) – attach additional sheets if necessary
1. Current Employer: Dates of Employment: From: To:
Title: Duties:
Address: City: State: Zip:
Phone Number: Fax #:
2. Previous Employer: Dates of Employment: From: To:
Title: Duties:
Address: City: State: Zip:
Phone Number: Fax #:
3. Previous Employer: Dates of Employment: From: To:
Title: Duties:
Address: City: State: Zip:
Phone Number: Fax #:
4. Previous Employer: Dates of Employment: From: To:
Title: Duties:
Address: City: State: Zip:
Phone Number: Fax #:
5. Previous Employer: Dates of Employment: From: To:
Title: Duties:
Address: City: State: Zip:
Phone Number: Fax #:
Professional Licensing History -- attach additional sheets if necessary
Are you now or have you ever been licensed, certified or registered as an Embalmer or Funeral
Director in any other jurisdiction? If yes, please list all licenses below.
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Yes
☐
No
Have you ever been licensed or are you currently licensed in this State or any other state for
any profession? If yes, please list all licenses below.
☐
Yes
☐
No
State/Jurisdiction License Type License # Date of Issue
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 4 of 7
Application and Instructions for Apprentice Embalmer Certificate of Registration
Nevada Funeral Board AE App Rev. 5/28/2020
Licensed Embalmer Information (Preceptor)
Name of embalmer which apprentice will serve under: License No.:
Establishment Name:
Address: City: State: Zip:
Education Requirements – Attach additional sheets if necessary.
Are you a high school graduate?
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Yes
☐
No
Have you completed at least 60 semester hours or 90 quarter hours at an accredited
college or university? (Credits earned as part of the core mortuary science program
do not fulfill this requirement.)
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Yes
☐
No
List all colleges and universities attended, and number of credits earned at each institution. Additionally, official
transcripts from each institution must be sent to the Board for verification of attendance and/or graduation.
Attach additional sheets if necessary
Name of School: Dates of Attendance: From: To:
Address: City: State: Zip:
Phone Number: E-mail Address:
Degree: Major: Number of Semester/Quarter hours obtained:
Name of School: Dates of Attendance: From: To:
Address: City: State: Zip:
Phone Number: E-mail Address:
Degree: Major: Number of Semester/Quarter hours obtained:
Name of School: Dates of Attendance: From: To:
Address: City: State: Zip:
Phone Number: E-mail Address:
Degree: Major: Number of Semester/Quarter hours obtained:
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 5 of 7
Application and Instructions for Apprentice Embalmer Certificate of Registration
Nevada Funeral Board AE App Rev. 5/28/2020
Military History Questions
Have you ever served on active duty in the Armed Forces of the United States and separated
from such service under conditions other than dishonorable?
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Yes No
Have you ever been assigned to duty for a minimum of 6 continuous years in the National Guard
or a reserve component of the Armed Forces of the United States and separated from such
service under conditions other than dishonorable?
Yes No
Have you ever served the Commissioned Corps of the United States Public Health Service or
the Commissioned Corps of the National Oceanic and Atmospheric Administration of the United
States in the capacity of a commissioned officer while on active duty in defense of the United
States and separated from service under conditions other than dishonorable?
Yes No
Are you currently a spouse of an active military service member?
Yes No
Nevada Business License Information- Please Check ONE appropriate answer.
I do NOT have a Nevada business license number and AM NOT required to have one under the provisions of
NRS Chapter 76.
I do NOT have a Nevada Business License number and AM required to have one under the provisions of NRS
Chapter 76.
I have a Nevada business license number assigned by the Secretary of State upon compliance with the provisions
of NRS Chapter 76.
Child Support Information – Please Check ONE appropriate answer.
I am not subject to a court order for the support of a child.
I am subject to a court order for the support of one or more children and am in compliance with the order or am
in compliance with a plan approved by the district attorney or other public agency enforcing the order for the
repayment of the amount owed pursuant to the order.
I am subject to a court order for the support of one or more children and am NOT in compliance with the order or
plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount
owed pursuant to the order.
Legal Information
Has there ever been a complaint filed, investigation, or legal action taken against any professional
license you have held for any reason?
Yes No
Are there any pending legal actions, complaints, investigations or hearings concerning you in
process?
Yes No
Have you ever had a professional license, certification or registration denied, restricted,
suspended, or revoked?
Yes No
Have you ever relinquished responsibilities, resigned a position or been fired while a complaint
was pending against you?
Yes No
(If you answer “YES” to any of the above questions, a Legal Reporting Form must be completed.
Form can be found on Board website or mailed upon request.)
Have you ever been convicted of, or pled guilty or nolo contendere to, a violation of ANY federal
or state statute, city or county ordinance, or any law of a foreign country? (Exclude minor traffic
violations.) (If you answer “YES” to this question, a Criminal History Form must be completed.
Form can be found on Board website or mailed upon request.)
Yes No
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 6 of 7
Application and Instructions for Apprentice Embalmer Certificate of Registration
Nevada Funeral Board AE App Rev. 5/28/2020
Certification and Signature
The undersigned hereby applies for a certificate of registration, under the laws and regulations governing funeral and
cemetery services and certifies that all statements and documents contained herein are true and correct to the best of
his/her knowledge and belief, that he/she is the person named in the credentials submitted, and the same were procured
in the regular course of instruction and examination, without fraud or misrepresentation; and with full knowledge that all
statements made in this application may be subject to investigation, and may include a check for fingerprints, police records,
and former employers. Applicant understands that if any responses on this application are false, fraudulent, misleading,
inaccurate or incomplete, the application may be denied. Applicant further understands that if a certificate is issued and it
is later determined that false or misleading information was provided, the certificate may be revoked.
Applicant agrees to allow the Nevada Funeral and Cemetery Services Board (“Board”) to communicate with any person in
connection with this application, and understands that any information submitted, including this application, may be deemed
a public record with the exception of any information deemed confidential by statute or regulation.
Signature of Applicant Date
Print Name
Applicant Photo – (Attach a 2” x 2” photo)
For Board Use Only:
Date Received:
Date Mailed:
Amount Paid:
License #:
Ref. #:
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 7 of 7
Application and Instructions for Apprentice Embalmer Certificate of Registration
Nevada Funeral Board AE App Rev. 5/28/2020
Credit Card Payment Information
Payment Method
Applicant Name:
☐ ☐ ☐ ☐
Amount: $
Name on Credit Card:
Credit Card Number:
Expiration Month/Year
Billing Address
Billing City, State & Zip
Email for Receipt:
Authorization
Signature:
By providing my signature, I authorize payment in the above amount to the Nevada Funeral and Cemetery Services Board for
the above application.
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Completed 27 October 2020

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