This application form is used by persons seeking licensure in Mississippi as a Funeral Service orFuneral Director Licensee and who is currently already licensed in good standing inanother state. Application by Reciprocity allows an appticant to provide evidence

satisfactor), to the Board that he or she holds a valid, unrevoked, and unexpired license asa fimeral service practitioner or funeral director in another state having substantially

similar requirements to the requirements for licensure as either an embalmer or fi-ureraldirector in this state.

Application For Reciprocity

I ) The application must be completed in full, either printed in black ink or typewfitten,except where signature is required. The Affidavit of Applicant statement must benotarized.

2) The application and appropriate fee of$200.00, must be returned to the address below.The app lication l'ee is NON-REFUNDABLE

3) Submit passing scores from the National cont'erence. (sent directly to the Board fromThe Conference) I'he National Conference's website is www.theconference.org.

4) Submit transcript from Mortuary School or college (sent directly to the Board lrom theschool or college) This is required for Funeral Service license only.

5) A license certification from each state you hold or have held a license in. (page 3 ofapplication form).

6) Once an application is deemed complete a license t-ee will be required. This fee isprorated and a letter will be sent advising of the amount due.

a. Licenses renew June 30th, bi-annually on the even years.

Mail to: 3010 Lakeland Cove, Suite W,Flowood MS 39232

Make check or money order payable to Mississippi Board of Funeral Service

Should you have any questions, please call board staff (@ 60l-932-1973.Wcb Page: ww\,!. msbft. nls.gov

Email: luneral boardalinlsbl.\.statc.ms_us

W*mffid&*@S

Type or Print in lnk Non-Refundable Application Fe€ $200.00

MISSISSPPI STATE BOARD OF FUNERAL SERVICEApplication to apply for license by Reciprocity

CHECK THE TYPE OF LICENSE APPLYING FOR:

-Funeral

Director Funeral Service (Embatmcr &Funeral Direclor)

PAR'I' I APPI,ICANT INFORI4ATION

Last

Name to appear on License: (Print)

SS#:

lrirsl \1idd le

Date of Birth: I I Gender: Male Female

Address

Cir\ State

)

zip

E-Mail Address

( cll Tclcp honc i(

II ]"ou havc secured cmployment in MS. list employer

PAR I I LICI:NSE I).lFOtu\I,\TION

Original Statc of l-iccnsure Ijuncral [)ircctor + Embalmer #

Was an apprcnticeship/internship completed? Ycs _ No _ Length of Apprenticeship

List othcr statcs you currcntly hold or have held a Funeral Iiccnsc in:

State

Statc

State

Liccnse No f)ate issued

License No Date issucd

License No Date issued

*A License Certification is required from each state*

llave you evcr had any license or registration to practice embalming, funeral directing, or cremations revoked. suspendcd, fined,

placcd on probation. or otherwise disciplined_ in this state or any other state orjurisdiction? yES_Do you have any actions pending? YES_ NO_Have you ever voluntarill' relinquished or surrendered a professional license or registration to practice embalming, funeral

directing, or cremations rvhile under investigation, or after initiation ofa disciplinary proceeding against you or the license?

YES_ NO_Have you ever had any license/registrarion application to practice funcral services denied? yES_ NO_lIa YIiS rcsponsc brietl) dcscribe

NO_

PART 3 IDUCATION INFORMATION

Namc o l' Mortuan Sciencc Program N here you grad uated

Copy ofCertified College Transcript \&as requested to besent tothe Funeral Board. ycs

Nan)c:

SteetorPOBoxHome Telephone:( )_

I

Nanrct

P,ARI 4 CRIi\,{INAL HISTORY

2)

ir

PAR I 5 N FFID A\ II OT APPLI("\\]

I hereby state under oath that my Funeral Director and/or Embalmer license has ncver been cancelcd. suspended or revoked.placed on probation, and at thc present time said license is in full lorce ard cffect. I furthcr state there is no prosecution pendingagainst me in any State or Fcderal Court for any felonious offensc ald thal I am the idcntical person to whom the license wasoriginally issued. and that the statements contained hercin are true and correct to the best of m); knowledgc. By submining thisapplication. I am providing a full and complete releasc to the liccnsing authority to any and all rccords and documentatioonecessar), to consider this application.

Subscribed and srvorn to belore me this the dav of

(Notan Seal)

County

Mv commission expires

A,D

Nota4 Public. in and lbr

State

Have you been convictcd of a felony? Yes-No_ If yes, briefly describe bclow and attach copies ofcoun documents

and an explanation ofthe charge, sentence. and disposition. Yes responses to Backeround ouestions will reouirc review bv The

Board.

Signature: _

STATE OF MISSISSIPPIMISSISSIPPI STATE BOARD OF FLINERAL SERVICE

30 IO LAKELAND COVE, SUITE WFLOWOOD, MS 39232

Office: (601) 932-1973 FAX: (601)932-1901msbfs.ms.gov

TO THE LICENSING AL,I?.FIORIfi': -fhc person indentil'ied below is applying for a professional license in the Stare of Mississ ippi and desircs Io

establish $|th Mrssjs i lhcir lrcense in our state lhanl u for ur:tssls1tutce.

Section 1 ADDlicant Ir formationFirst Namo:

Date of Birthi Social Security Number:

Section Licensure I nforma tion b\ Responding Statelhis $ill certrry that the Appl icant is cunendy licensed in good standing in this slate in thc following category(s) (pleaJe circla applicabh

uestcd infonnation(.ATEGORY Date Expites

Embalmer NoFuneral Director Yes No

Section 28. Exam Informa tion from Responding StateThe records ofthis S

applicable).tate indicate that the Applicanl hfls taken the exam(s) indicated belorv and achieved the scores indicated (tG-ase circle

Exam (circle qplicahle iterni) Scorc ("o c|ftect sr'ct) llloith & Vat cxamta*enAn examinalion administered by the Boardand preparcd by the Conlcreoce.Science Section ofthe Nalional Board Exarn,adminislered bv the Con|rencc ofFuncralSarvice Ixamining Boaids

Arts Seclion ofthe National Board Exam.administered by the Conltrence ofFuncralSarvice Examining Boards

An examination prepared and administercd bythis state.

S 3 rv ActionI las _ I las not _taken disciplinary action against thc licensc referrcd to in this Certif;cationDetails oI Disciplinary Acrion (atrach addirional sheets)

Section 4. S of ndi Authori tf el_

Signature Print Nainc Dare

SIALState:_

CERTIFICATION OF LICENSURE

lUiddle lnitial: Last \amc:

I

Yes