KBEFD Courtesy Card Application

Courtesy Card Application

Resident State Information

* License Number (Issued by your resident state)

* Resident State

* Date

Verification of Active Status (Verification must be uploaded or received by the Board office for application approval).

Applicant Information

* Applicant Name

* EMPLOYMENT: (Name of Funeral Home):

* Street Address

* City

* State

* Zip

* Phone Number

* Last 4 of SSN

Convictions and Suspensions

* Have you ever been convicted of any criminal offense other than a minor traffic violation?

Yes

* Have your licenses ever been suspended?

Yes

* Have your licenses ever been probated?

Yes

* Have you been otherwise found in violation of the Board Laws?

Yes