New Jersey Ofce 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 Reinstatement of a Funeral Director’s License
Complete the following information. Please print clearly.
Name: ______________________________________________________________________
Address: ____________________________________________________________________
Street
____________________________________________________________________________
City State ZIP code
Home telephone number:__________________ Work telephone number: ________________
(include area code) (include area code)
Fax number: ___________________________ N.J. License No.: ______________________
(include area code)
Date of birth: ___________________________ Date of last renewal: ______________________
Month Day Year
Month Day Year
*Social Security No.: ______ - ______ - ______
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e
of the New Jersey Child Support Enforcement Law, Section 1128E(b)(2)A of the Social
Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board is required to obtain your Social
Security number. Pursuant to these authorities, the Board is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including
for the purpose of reviewing compliance with State tax law and updating and correcting
tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon
request.
Answer the following questions regarding the time period since you were last licensed in
New Jersey. For all “Yes” answers, provide sufcient details on a separate sheet of paper.
1. Has any action been taken, or is any action pending, against your professional license or
certicate, or have you been permitted to surrender or otherwise relinquish your license to
avoid inquiry, investigation, or action by any state or jurisdictional licensing authority
that you have not already reported to this Board?
Yes No
2. Have you been arrested, charged or convicted of any crime or offense that you have not
already reported to this Board? (Minor trafc offenses, such as speeding or parking need not
be provided, but motor vehicle offenses such as driving while impaired or intoxicated must be
disclosed.)
Yes No
If you answered “Yes” to either of these questions, you must describe the circumstances
surrounding the event(s) on a separate piece of paper, and provide copies of the relevant
complaint(s), indictment(s), judgment(s), order(s), and any other ofcial documents which relate
to the event(s) in question.
