Fillable Funeral Arranger Renewal Application (State of Nevada, Department of Information Technology)

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Funeral Arranger Renewal Application (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 FA Renewal Rev. 10/14/2019
FUNERAL ARRANGER LICENSE RENEWAL
Information and Instructions
Any individual wishing to renew a Funeral Arranger’s License in the State of Nevada must complete this renewal
application form and submit to the Board with required documents and fees by January 1, 2020. Mail your completed
application and fees to the Board at the above address.
Required Documents
☐
☐
☐
Please note that renewal applications received after February 1
st
will be charged at $275 and will not be able to
be completed online. In no case shall the late renewal fee be waived.
Applicant Information
Full Legal Name:
License No.:
Home Mailing Address:
City:
State:
Zip Code:
Phone Number:
E-mail Address:
Place of Employment:
Work Mailing Address:
City:
State:
Zip Code:
Phone Number:
E-mail Address:
Preferred Mailing Address (all Board correspondence will be sent to this address):
☐
Home
☐
Work
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?
☐
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
CLEAR
STATE OF NEVADA FUNERAL AND CEMETERY SERVICES BOARD Page 2 of 2
Funeral Arranger License Renewal Application
Nevada Funeral Board FA Renewal Rev. 10/14/2019
Nevada Business License Information - Please check ONE appropriate answer. Any individual working
as an independent contractor may be subject to business license requirements. An answer is mandatory.
☐
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. An answer is mandatory.
☐
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 may 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
Since the date the last license was issued, has there been any legal or disciplinary
action taken against any professional license held in any state for any reason?
☐
Yes
☐
No
Are there any pending legal actions, complaints, investigations or hearings
concerning you in process?
☐
Yes
☐
No
Since the date the last license was issued, have you had a professional license,
certification or registration denied, restricted, suspended, or revoked?
☐
Yes
☐
No
Since the date the last license was issued, have you relinquished or surrendered
any license, permit or certificate while under investigation, or after initiation of a
disciplinary proceeding?
☐
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.)
Since the date the last license was issued have you 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? (Excluding minor traffic violations.) If
“yes” is checked, a “Criminal History Form” must be completed by each person for
whom this answer applies. Form may be found on the Board website or mailed
upon request.
☐
Yes
☐
No
Declaration of Applicant
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 relevant to this application.
Signature of Applicant
Date
For Board Use Only:
Date Received:
Amount Paid:
Ref. #:
Date Mailed:
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Completed 27 October 2020

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