Model Application. Funeral Service. For. Presented By:

Transcription

1 Model Application For Funeral Service Presented By: Model Application 2016

2 I The Interna onal Conference of Funeral Service Examining Boards is pleased to introduce The Conference Model Applica on. Recognizing the variety of requirements among members, the goal of the commi ee was to collect research and compile a universal document to be used in licensing individuals. The primary purpose of The Model Applica on is providing a resource for the funeral service regulatory community in reques ng/requiring the disclosure of per nent informa on on the applica on of a poten al licensee. Much like The Conference Model Prac ce Act, The Model Applica on will promote standardiza on of terminology and requirements which will be er facilitate public understanding of the profession. Regulatory officials can review subsec ons which are applicable to their exis ng laws and rules, with the availability of unrequired informa on for review and considera on in the future. Addi onally, The Model Applica on will increase licensure portability through uniformity and consistency. The Model Applica on Commi ee was appointed by the Board of Directors in August 2015, comprised of representa ves from five of The Conference s member jurisdic ons. The commi ee held mul ple mee ngs via conference call over the course of several months; the final product includes the composi on of these mee ngs as well as research by individual commi ee members in the interim. A final dra of The Conference Model Applica on was approved by the Commi ee on January 19, 2016, by the Board of Directors on January 22, 2016, and adopted by the delegate assembly at the 112 th Annual Mee ng on February 24, The Conference Model Applica on includes sec ons on candidate iden fica on, educa on, examina on(s), internship, work history, prior licensing, discipline/criminal history, substance abuse/mental health, background check and a esta on. If your jurisdic on is considering amending your applica on form, please refer to this model for suggested ques ons, informa on, requirements and language. 1

3 General Instruc ons and Important No ce: Comple on of this applica on form is necessary for considera on for licensure as a in (insert state/province), according to (insert applicable Laws). Failure to disclose all requested informa on may result in this form not being processed and may subsequently result in denial of this applica on. All candidates for ini al licensure, renewal, and/or examina on have a con nuing obliga on to update and supplement the informa on and responses on this applica on if they change. Failure to supplement the informa on and responses provided on this applica on may result in denial or other appropriate ac on. All informa on provided must be accurate. Please note that the informa on provided on this applica on is subject to the public informa on laws of this jurisdic on. Carefully follow the direc ons on this applica on form. In addi on, note the following: 1. Type or print legibly with black or blue ink only. 2. The licensure and applica on fees are NOT refundable. 3. Disclosure of your U.S. social security number, if you have one, is mandatory. The disclosure is mandated by (insert federal and state statutory provision). The social security number will be provided to the Department of (i.e. Public Aid) to assist in the iden fica on of persons who are delinquent in complying with a child support order, spousal support/alimony order or in the repayment of educa onal loans. 4. If the name shown on your suppor ng documents is different from that shown on your applica on, you must submit proof of legal name change a cer fied copy of your marriage license, divorce decree, affidavit or court order. Suppor ng Documenta on and Fees: If you are applying for licensure as a, submit the following documents and fees: INSERT LIST OF DOCUMENTS AND FEES HERE FOR EXAMPLE: Applicable Fee Official Transcript submi ed directly from mortuary science program Verifica on of Licensure (from all jurisdic ons previously licensed in) Cer fica on of Supervision/Internship/Experience Cer fied copy of NBE scores sent directly from ICFSEB Criminal Background Check Applica on Your applica on is NOT considered complete un l all suppor ng documents and fees have been received by the (Insert Name of Licensing Authority here.) 2

4 P I. A I I First Name Middle Name Last Name Suffix Social Security Number Date of Birth MM/DD/YY Male Female Public Address (If PO Box, Must provide street address as well) City State Zip Address of Record including postal code (If different than above) City State Zip Home Phone Work Phone Cell Phone Iden fy any maiden name, surname, or any other names or aliases you have been known by or used and iden fy the reason for your name change. Are you a U.S. ci zen? Yes No If you answered no to the above, please specify if you are: a qualified alien (as defined in 8 U.S.C.A. 1641), a nonimmigrant under the Immigra on and Na onality Act (8 U.S.C.A et seq), an alien who is paroled into the United States under 8 U.S.C.A. 1182(d)(5) for less than one year, a foreign na onal not physically present in the United States. If other, please explain: P II. E List the educa onal ins tu ons a ended that sa sfy the educa onal requirement for licensure. High School/GED ins tu on a ended Gradua on Date MM DD YY Mortuary School A ended Degree (Official Transcript Required) Gradua on Date MM DD YY P III. E I Have you passed the Na onal Board Exam (NBE) administered by The Interna onal Conference of Funeral Service Examining Boards (ICFSEB)? Yes No Month/Year passed: *You must have a cer fied copy of your NBE results sent to this licensing agency directly from ICFSEB. 3

5 P IV. I H You must include each jurisdic on and/or establishment where interned. Please make a copy of this sheet and a ach if necessary. Jurisdic on Internship Served in: Internship Registrant Number: Internship Start Date: Internship Comple on Date: Name of Establishment: Address: City: State: Zip: Phone Number: Type of Internship: Dates of Training: Name of Approved Supervisor: Name of Establishment: Address: City: State: Zip: Phone Number: Type of Internship: Dates of Training: Name of Approved Supervisor: Name of Establishment: Address: City: State: Zip: Phone Number: Type of Internship: Dates of Training: Name of Approved Supervisor: P V. W H List all employment chronologically within the last five years to the present. (May con nue on next page). If you have never been employed, insert N/A for Not Applicable. Name of Establishment: Job Title: Address: City: State: Zip: Name of Licensed Manager Dates of Employment: May we contact the Licensed Manager? Yes No Name of Establishment: Job Title: Address: City: State: Zip: Name of Licensed Manager Dates of Employment: May we contact the Licensed Manager? Yes No 4

6 P V. W H CONTINUED Name of Establishment: Job Title: Address: City: State: Zip: Name of Licensed Manager Dates of Employment: May we contact the Licensed Manager? Yes No Name of Establishment: Job Title: Address: City: State: Zip: Name of Licensed Manager Dates of Employment: May we contact the Licensed Manager? Yes No P VI. P If you have ever been licensed, cer fied or registered to prac ce in the profession for which you are now making applica on, or held any other professional license, cer fica on or registra on, complete the informa on requested below. *Under status: Please note if license is ac ve, inac ve, or lapsed. (Failure to completely disclose above informa on, could result in automa c denial.) Jurisdic on(s): Type of license: License number: Effec ve dates of licensure: Status: 5

7 P VII. P D A Please ini al next to Yes or No for each. Have you ever had any license to prac ce embalming, funeral direc ng, direct disposing, or any other regulated profession, revoked, suspended, fined, placed on proba on, reprimanded, or otherwise disciplined, by any regulatory authority in this state or any other state or jurisdic on? YES NO Do you have any ac ons pending? YES NO Have you ever voluntarily relinquished or surrendered a professional license while under inves ga on, or a er ini a on of a disciplinary proceeding against you or the license? YES NO Have you ever had any license/registra on applica on to prac ce funeral services denied? YES NO If you answered yes to any of the ques ons above, submit no ces, orders, etc. from the appropriate regulatory board and include a wri en statement/explana on rela ng to any disciplinary ac on. P VIII. C H Please ini al next to Yes or No for each. Have you ever been convicted of a misdemeanor or a felony in this or any other state, local jurisdic on, or any other foreign country, or are criminal charges currently pending against you? YES NO If yes, a ach an explana on that includes the type of viola on, the date, circumstances and loca on, and the complete penalty received. Also include copies of court documents, arrest records, verifica on of res tu on received by the court, and verifica on of successful comple on of proba on. You must include all misdemeanor and felony convic ons, regardless of the age of the convic on, including those which have been set aside and/or dismissed. (Traffic viola ons of $ or less need not be reported). P IX. S A /M H Please ini al next to Yes or No for each. Do you currently have or have you been previously diagnosed with any condi on or impairment (including but not limited to, substance abuse, alcohol abuse, or a mental, emo onal or nervous disorder or condi on) that in any way affects your ability to prac ce as a in a competent, ethical, and professional manner? YES NO If yes to above ques on, please a ach le er explaining. P X. B C I understand that I, as an applicant seeking a license from the (name of licensing authority) must consent to a background check. I further understand that a background check may result in the (name of licensing authority) obtaining informa on including but not limited to misdemeanor and felony arrests and convic ons (may also include juvenile and expunged records), motor vehicle viola ons, state and federal tax liens, civil ac ons, child/spousal support, educa on loan repayment obliga ons, and previous and current licensure discipline. Ini al here: 6

8 P XI. C S I hereby cer fy under penalty of perjury that I have read this applica on in its en rety. The responses and a ached materials I have provided are true and accurate to the best of my knowledge. I further cer fy that I am of good moral character and have reviewed and will at all mes comply with all applicable state laws, rules and regula ons governing the license I am seeking to obtain. I hereby authorize and direct any person, agency, firm, or other en ty to release, upon the request of (name of licensing authority), any informa on, communica on, report, record, statement, recommenda on, or disclosure that may have bearing on my eligibility for or con nuance of the license for which I am applying. I understand that by signing this applica on, I am authorizing the release of informa on about me that may otherwise be protected or confiden al. Addi onally, I understand and agree that any false informa on, misrepresenta on, or omission of facts in this applica on and during the applica on process is cause for denial of this applica on. Signature of Applicant (Do not print) Printed Name of Applicant Date Subscribed and sworn to or affirmed before me this day of,. Signature of Notary Public My commission expires: Seal or stamp must be affixed. 7