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
Mortuary Continuing Education Provider Form
Applicant/Sponsor:
Name: ________________________________________ Company: __________________________________
Telephone: ______________________ Fax: ____________________ Email: ____________________________
Include area code Include area code
Address: ___________________________________________________________________________________
Street City State ZIP code Country
Application type: Initial application Second request for consideration Change/course update
CE credit type: In person Preneed In person Ethics In person laws/rules OSHA
Other
Program information: Each individual topic/course/unit must have its own application
Program title: Number of CE hours
requested:
Program dates: Program location:
Program description:
Program objectives:
*
One hour of CE credit includes 50 minutes of instruction excluding registration time, breaks, and meals.
Instruction:
Facilitators/Instructors:
(attach bios/resumes with contact information)
Method of instruction (check all that apply):
In person lecture/presentation Teleconference/webinar Correspondence course
Online course Other (describe):
Attendance method: Fees/Charges:
Contact information to register for course:
Attach all documentation for consideration including study materials, sample exams, self-study printed
materials, and proof of approval by other agencies.
* Providers should review rules at N.J.A.C. 13:36-10.1, 10.3, and 10.9 about the Board of Mortuary Science’s
continuing education requirements.
