application for mortician license via waiver of ... · application for mortician license via waiver...

APPLICATION FOR MORTICIAN LICENSE VIA WAIVER OF APPRENTICESHIP

REQUIREMENTS – REQUIRED DOCUMENTS

Requirements per COMAR 10.29.09

Received Date

received Required Documents

☐ Certified Copy of College Transcripts for Mortuary Science Degree

☐ Completed License Verification for Waiver of Apprenticeship

Requirement Form from the State where you were initially licensed

(BOM form)

☐ Letter from Employer(s) Verifying Applicant has practiced Funeral

Direction or Mortuary Science for at least 5 years uninterrupted

☐ Letter of Good Standing from any other states where you are licensed to

practice Mortuary Science or Funeral Service.

☐ Criminal History Background Check Receipt

☐ Background Check and Fingerprinting Completed by CJIS Results

Emailed to the Board of Morticians

☐ Law Exam – BOM (Successfully Pass)

☐ Passport Size Photo

☐ Certified Official National Board Exam Scores sent directly to the Board

of Morticians

In addition to the application and $600.00 application fee, the above documents are required for

Waiver of Apprenticeship requirements and must be received 2 weeks in advance of the

scheduled board meeting for consideration.

APPLICATION FOR MORTICIAN LICENSE

VIA WAIVER OF APPRENTICESHIP REQUIREMENTS

Morticians Licenses expire April 30th every two years. The application fee is $600.00.

NAME: ___________________________________________

HOME ADDRESS: ____________________________________________________________________

____________________________________________________________________

HOME TELEPHONE: _(____)_______________ WORK TELEPHONE: _(___)__________________

EMAIL ADDRESS: _________________________________________________________

PLACE OF EMPLOYMENT: ___________________________________________________________

___________________________________________________________

SOCIAL SECURITY #: __________________________ DATE OF BIRTH: _____________________

APPRENTICE LICENSE #: _______________________ DATE ISSUED: _______________________

RACE (Please circle all applicable; for statistical purposes only): 1 – White 2 – Black or African

American 3 – American Indian or Alaska Native 4 – Native Hawaiian or Pacific Islander

5 – Asian 6 – Hispanic / Latino 7 – Other

MORTUARY SCHOOL COMPLETED: __________________________________________________

DATE OF COMPLETION: ___________________ DEGREE RECEIVED: ______________________

(Ensure a copy of your certified transcripts is provided to the Board)

DATE NATIONAL BOARD EXAM COMPLETED: _____________________ PASS: Y / N

PROVIDE THE FOLLOWING INFORMATION FOR LICENSES HELD IN OTHER STATES

__________________________________________ _________________________________________

STATE LICENSE # STATE LICENSE #

__________________________________________ _________________________________________

STATE LICENSE # STATE LICENSE #



2

YES

NO

1)

Has the use of drugs and/or alcohol resulted in an impairment of your

ability to practice in your profession?

2) Has any licensing or disciplinary board in any jurisdiction, or an entity of the Armed services, denied your application for licensure, reinstatement or renewal; taken any action against your license, including but not limited to, reprimand, suspension, revocation, fine or non-judicial punishment?

3) Have you surrendered or allowed your license to lapse while under investigation by a licensing or disciplinary board in any jurisdiction or an entity of the Armed Services?

4) Are you currently under investigation or have any complaints or charges

been brought against you or are currently pending, in any jurisdiction, by

any licensing or disciplinary board or entity of the Armed Services?

5) Have you ever been convicted, pled guilty, or received probation before

judgment of any criminal act or for driving while intoxicated, or for a

controlled dangerous substance offense (excluding minor traffic

violations)?

6) Have you been diagnosed with a physical or mental condition which may affect your ability to practice the profession of mortuary science?

(If yes is checked on any item above, please explain on a separate sheet of paper)



3

Applicant Signature

I certify that the above statements, to the best of my knowledge and belief are true, correct,

complete, and made in good faith. I do solemnly swear to perform my duties in compliance with

all laws, rules, and regulations of the Maryland State Department of Health, the Maryland Board

of Morticians and Funeral Directors, and the State of Maryland.

______________________________________________________________________________ Applicant Signature Date

STATE: ________________________________

CITY/COUNTY: __________________________

I HEREBY CERTIFY that on this ______ day of ________________, 20__, before me, a

Notary Public of the State and City/County aforesaid, personally appeared

______________________ and made oath in due form of law that signing the foregoing

Application for Licensure was the voluntary act and deed of _________________________.

AS WITNESSETH my hand and Notarial Seal.

SEAL

___________________________________________

Notary Public

My Commission Expires: _______________________

LICENSE VERIFICATION FOR WAIVER OF APPRENTICESHIP REQUIREMENTS

(To be completed by State Board of initial licensure)

NAME: ___________________________________________

TYPE OF LICENSE: ____________________________ LICENSE #: ___________________________

DATE OF ORIGINAL ISSUE: ____________________________

DATE OF MOST RECENT ISSUE: ____________________________

HAS THE LICENSEE PRACTICED CONTINUOUSLY IN THE STATE FOR AT LEAST 5 YEARS

PRECEDING THIS WAIVER REQUEST? Y / N

IS THIS LICENSEE CURRENTLY IN GOOD STANDING WITH YOUR STATE? Y / N

WHAT ARE YOUR STATE’S STANDARDS FOR A LICENSE?

EDUCATION:

____HS DIPLOMA ____AA/AS DEGREE

____BA/BS DEGREE ____MORTUARY SCIENCE DIPLOMA

NATIONAL CONFERENCE EXAMINATION SCORES? Y / N

APPRENTICESHIP HOURS REQUIRED BY STATE: ____________

WILL YOUR STATE GRANT A SIMILAR WAIVER TO MARYLAND LICENSEES? Y / N

ON BEHALF OF THE STATE OF ________________________ FUNERAL SERVICE BOARD, I

CERTIFY THAT THE ABOVE STATEMENTS ARE CORRECT.

___________________________________________ ___________________________

SIGNATURE OF AUTHORIZED OFFICIAL DATE

___________________________________________

NAME AND TITLE OF AUTHORIZED OFFICIAL

STATE OF MARYLAND DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY

LIVESCAN PRE-REGISTRATION APPLICATION

APPLICANT INFORMATION (PLEASE TYPE OR PRINT CLEARLY) Name: Date of birth: SSN: Gender: Male Female (Please check)

Height: ft. inches Weight: lbs. Eye Color: Hair Color: Race: Black White )Asian/Pacific Islander Native American Other (Please check) Place of Birth: Citizenship: Current address:

City: State: ZIP Code: - Daytime Phone: Evening Phone: Driver’s License #:

AGENCY INFORMATION Agency Authorization #: ORI # (if required): Reason fingerprinted? Position Applied for: Request Type: (Choose one ONLY)

Adult Dependent Care Attorney/Client Child care Criminal Justice Gold Seal/ Adoption Gold Seal/Letter/VISA Government Employment

Government Licensing or Certification Immigration/VISA Individual Challenge Individual Review MSP Licensing Private Party Petition

Public Housing

Mail Response to: (Mailing option only available for Visa Gold Seal and/or Individual Review)

Name: ________________________________________________________________________________________

Address: _______________________________________________________________________________________

City, State, Zip code: ______________________________________________________________________________

1400003636