KBEFD Courtesy Card Application
Courtesy Card Application
Resident State Information
* License Number (Issued by your resident state)
* Resident State
Indiana
Ohio
Virginia
West Virginia
* 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
(Select)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
U.S. Minor Outlying Islands
U.S. Virgin Islands
* 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
No
* Have your licenses ever been suspended?
Yes
No
* Have your licenses ever been probated?
Yes
No
* Have you been otherwise found in violation of the Board Laws?
Yes
No