Fillable FUNERAL AND CEMETERY SERVICES BOARD Legal Reporting Form (State of Nevada, Department of Information Technology)

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FUNERAL AND CEMETERY SERVICES BOARD Legal Reporting Form (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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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 Legal Reporting Rev. 8/21/2017
Legal Reporting Form
Information
This form is used in conjunction with various license application forms to provide details concerning legal
actions. (Complaints, License Suspensions, Restrictions, and Revocations.)
Applicant Information
Facility or Individual Name:
Details (please describe any legal action, complaints, investigations, or professional license restrictions below)
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.
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FUNERAL AND CEMETERY SERVICES BOARD Legal Reporting Form (State of Nevada, Department of Information Technology)

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Completed 3 November 2021

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