NORTH CAROLINA BOARD OF FUNERAL SERVICE
1033 WADE AVE., SUITE 108 PHONE (919) 733-9380
RALEIGH, NC 27605 FAX (919) 733-8271
(COMPLETE ALL INFORMATION ON FRONT AND BACK OF THIS FORM)
Establishment permits expire December 31, 2008
Renewal fee is due by December 31, 2008.
Renewal fee is $150.
Renewal fees received after 2-1-09 must include a $100 late fee.
APPLICATION FOR RENEWAL OF FUNERAL ESTABLISHMENT PERMIT
1. Business Name of Funeral Establishment:
2. PO Box Street Address
City County Zip
Phone # Fax # E-mail
3. Does this establishment claim the “grandfather clause” because it held an establishment permit on January 1, 1988, and
the controlling interest has not been sold .
4. Establishment Owned by: (A) Individual (B) Partnership (C) Corporation (D) Limited Liability Company
(A) List the name and license number of the: Individual Owner (individual must be licensed by the Board as a funeral director
or a funeral service licensee)
(B) Partners (at least one partner must licensed by the Board as a funeral director or a funeral service licensee)
(C) Corporation name, including parent corporation if applicable, the names of officers and their positions (an individual licensed
by the Board as a funeral director or a funeral service licensee must be the President, Vice President or Chairman of the Board of
(D) Members of Limited Liability Company (at least one must be licensed by the Board as a funeral director or funeral service
5. If the establishment is owned by a corporation, Limited Liability Company or partnership, is that entity currently in good standing
with the NC Secretary of State? (i.e. has not been administratively dissolved, revoked, or placed on revenue suspension.)
Yes No (if no, attach a statement of explanation)
6. Has the individual owner, any partner, any officer or member of the board of directors, or member of the limited partnership ever been
denied a license to engage in any occupation or profession in any state, the District of Columbia or any foreign country, had such
license suspended, revoked or placed on probation, or been convicted of a crime, either a misdemeanor or felony?
If you answered yes, attach a statement giving complete details relating to any criminal convictions. For issues relating to an
occupational or professional license include jurisdiction, reason for denial the violation that led to action against license Please
include relevant documents from the judicial system or from the licensing authority.
7. Does the applicant have the right to occupy the property by lease or deed? Yes No
8. Does the Preparation Room meet the statutory requirements of N.C. General Statute 90-210.27A? ___ Yes ____ No
Have any changes been made in the preparation room since the last renewal? ____Yes ____ No
9. This establishment currently holds a Preneed License. Yes No
This establishment sells: Trust funded preneed Insurance funded preneed
10. If embalming is done in an off-premises embalming facility, state name and address:
11. This Establishment's Funeral Directors, Embalmers and Funeral Service Licensees:
NAME TYPE & LICENSE # FULL TIME PART TIME PER CASE
12. Name and license number of the location manager. (Do not name a “general” manager.) Must be a North Carolina
licensed Funeral Director or Funeral Service licensee who maintains the immediate and personal supervision, direction
and control of the funeral establishment:
Manager’s name and license number
NORTH CAROLINA VERIFICATION
, being duly sworn, deposes and says that he (she) is
Name of Licensed Location Manager Signing Application
manager of and that he (she) has read
Name of Funeral Establishment
the foregoing application and the same is true of his (her) own knowledge.
Signature & License Number of Location Manager
Sworn to and subscribed before me by this the
Name of Applicant
day of , 20 .
Notary Public – Official Signature
Notary Public – Printed Name
My commission expires:
Pursuant to 21 NCAC 34A.0202 and G.S. 25-3-506, a fee of $25.00 will be charged for returned checks. FORM BFS-17