Georgia Funeral Service Apprenticeship Form PDF Details

The Georgia Funeral Service Apprenticeship form serves as a pivotal step for individuals looking to embark on a career in the funeral service industry within the state of Georgia. Issued by the Georgia State Board of Funeral Service, this comprehensive application outlines the requirements and procedural guidelines for both initiating and making any necessary changes to an apprenticeship in funeral services. Applicants are meticulously advised to review Board Rule, Chapter 250-4, which contains essential information on apprenticeship requirements, directly accessible through the board's website. Key components include the non-refundable application fee, eligibility criteria such as age and educational background, alongside specifics about the apprenticeship like its start date, duration (a minimum of 18 months, extendable up to 36 months with renewals), and the mandated 3120 hours of full-time service. Furthermore, it mandates apprenticeship under a board-approved establishment and supervisors, delineating the process for reporting and recording service hours, as well as procedures for any changes in location or supervisor that would necessitate new application submission. Instructions and affidavit sections for both apprentice applicants and their supervising embalmers and directors are included to ensure compliance and veracity of the information provided. This form not only ensures the structured and regulated entrance into the funeral service profession but also aims to maintain the high standards of practice expected within Georgia.

QuestionAnswer
Form NameGeorgia Funeral Service Apprenticeship Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesfuneral director apprenticeship georgia, apprenticeship forms for macon ga, georgia funeral form, georgia secretary of state funeral service

Form Preview Example

GEORGIA STATE BOARD OF FUNERAL SERVICE

237 COLISEUM DRIVE

MACON, GA 31217

478.207.1460

FAX 478.207.1468

www.sos.state.ga.us/plb/funeral

FUNERAL SERVICE APPRENTICESHIP

INSTRUCTIONS FOR APPLICANTS

FOR INITIAL REGISTRATION OR ANY CHANGE IN LOCATION OR SUPERVISOR

RULE 250-4

Before filing an application for registration as a Funeral Service Apprentice,

 

 

please read Board Rule, Chapter 250-4, which details specifically the

 

 

requirements for apprenticeship. The rule may be reviewed on our website.

REQUIREMENTS

 

 

 

 

FEE

Refer to fee listing on the application. Application fees are non-refundable.

 

 

Make payment by check or money order to Georgia State Board of Funeral

 

 

Service.

AGE

You must be 18 years of age on the date that the Board receives your application.

EDUCATION You must attach a copy of your high school diploma or GED Certificate to this application.

 

 

APPRENTICESHIP DETAILS

DATE OF

The date your apprenticeship begins will be determined by the date your

 

REGISTRATION:

application is approved by the Board. The Board will approve your

 

 

application only when it is completed. It is imperative that you the

 

 

applicant review your application prior to submitting it to the Board office,

 

 

as incomplete applications will result in unnecessary delays in the approval

 

 

of the applications.

HOURS:

3120 hours(the equivalent of 18 months of full-time service).

 

 

 

DURATION:

A minimum of 18 months. The apprenticeship registration, which is valid

 

 

for two years, may be renewed twice. The apprenticeship time is in

 

 

addition to the time required to graduate from a college of funeral service or

 

 

other college.

SUPERVISION:

An apprentice must serve at a Board-approved establishment and under a

 

 

Board-approved embalmer and funeral director.

REPORTS:

An apprentice must complete report forms which may be obtained from the

 

 

Board office or on the Board website. It is the responsibility of the

 

 

apprentice to maintain records of service.

CHANGES:

An apprenticeship is approved for a specific establishment and under a

 

 

specific supervising embalmer, funeral director, or both. Any change shall

 

 

terminate the apprenticeship immediately. You must then submit a new

 

 

application, which must be presented to the Board for approval. Reports

 

 

must be kept current and must be available for review by the Board

 

 

inspector.

 

 

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GEORGIA STATE BOARD OF FUNERAL SERVICE

237COLISEUM DRIVE MACON, GA 31217

478.207.1460 FAX 478.207.1468

www.sos.state.ga.us/plb/funeral

DO NOT WRITE IN THIS SECTION

RECEIPT # _____________________

AMOUNT ______________________

APPLICANT # __________________

INITIAL _____ DATE ___________

APPLICATION FOR FUNERAL SERVICE APPRENTICESHIP

REASON FOR APPLICATION:

Make checks payable to: The GA Board of Funeral Service

(

)

Initial Funeral Service Apprenticeship

$

40.00

Non Refundable

(

)

Change in Apprenticeship Site(to include change of supervisors)

$

20.00

Non Refundable

(

)

Change in Supervising Embalmer&/Or Funeral Director Only

$

20.00 Non Refundable

(

)

Reinstatement of Apprenticeship Registration # ___________

$180.00

Non Refundable

Instructions:

-Apprentice Applicant must complete Part I and Part V

-Supervising Embalmer must complete Part II

-Supervising Funeral Director must complete Part III

-Funeral Director in Full & Continuous Charge, on behalf of the Funeral Establishment, must complete Part IV

PART I – APPRENTICE APPLICANT (Please print or type)

FIRSTMIDDLELAST

*FOR CHANGE OF SITE OR SUPERVISOR ONLY, LIST APPRENTICESHIP REGISTRATION #_________

CURRENT RESIDENCE ADDRESS

___________________________________________________________________________________________________________

STREET(INCLUDE APT/LOT #)

CITY

COUNTY STATE ZIP CODE TELEPHONE NUMBER

SOCIAL SECURITY NO.*: ______-____-_________

*THIS INFORMATION IS AUTHORIZED TO BE OBTAINED & DISCLOSED TO STATE & FEDERAL AGENCIES PURSUANT TO O.C.G.A. § 19-11-1 & O.C.G.A. § 20-3-295, 42 U.S.C.A. § 551 & 20 U.S.C.A. § 101.

U.S. CITIZEN : _____ YES _____ NO*

*LIST CITIZENSHIP:_______________________________________

& SUBMIT A COPY OF REGISTRATION CARD

PLACE OF BIRTH:

______________________________________________

CITYSTATE OR COUNTRY

AGE: ________

DATE OF BIRTH : _______/_________/_____________

GENDER

: _____ MALE _____ FEMALE

__________

__________

__________

__________

HEIGHT

WEIGHT

EYES

HAIR

APPRENTICESHIP SITE INFORMATION

________________________________________________________________________

________________________________

FUNERAL ESTABLISHMENT NAME

LICENSE NUMBER

________________________________________________________________________

 

SUPERVISING DIRECTOR

LICENSE NUMBER

________________________________________________________________________

 

SUPERVISING EMBALMER

LICENSE NUMBER

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PART I – APPRENTICE APPLICANT (CONTINUED)

The Apprentice Applicant must answer the following questions. If your answer is “Yes” to any of the following questions, please explain, giving current status and attach additional sheets and documentation, if necessary.

(

)

Yes

(

)

No

Are you currently registered as an Apprentice?

 

 

 

 

 

 

If “Yes,” please provide your Apprentice Registration Number:________________

(

)

Yes

(

)

No

Have you ever been registered you as an Apprentice in this state?

 

 

 

 

 

 

If “Yes,” please provide your Apprentice Registration Number:________________

(

)

Yes

(

)

No

Are you a high school graduate, or have you obtained a GED Certificate?

 

 

 

 

 

 

You must attach a copy of your diploma or GED certificate to this application.

(

)

Yes

(

)

No

Do you now hold, or have you in the past held, a professional license in any state?

 

 

 

 

 

 

If “Yes”, submit an original notarized letter from the state of licensure.

(

)

Yes

(

)

No

Have you had revoked or suspended or otherwise sanctioned any license issued to you

 

 

 

 

 

 

by any board or agency in Georgia or any other state?

(

)

Yes

(

)

No

Were you denied issuance of or, pursuant to any disciplinary proceedings, refused

 

 

 

 

 

 

renewal of a license by any board or agency in Georgia or any other state?

(

)

Yes

(

)

No

Have you knowingly failed to renew a license during an investigation or disciplinary

 

 

 

 

 

 

action?

 

 

 

 

 

 

 

(

)

Yes

(

)

No

Have you been subject to disciplinary action or had your membership revoked by a

 

 

 

 

 

 

professional organization governing the practice of that profession?

(

)

Yes

(

)

No

To the best of your knowledge, is there any disciplinary action pending against you by

 

 

 

 

 

 

any licensing board or professional organization?

(

)

Yes

(

)

No

Have your been arrested, charged or sentenced for the commission of a felony or any

 

 

 

 

 

 

crime involving moral turpitude?

(

)

Yes

(

)

No

Are you unable to practice with reasonable skill and safety due to illness or use of

 

 

 

 

 

 

alcohol, drugs, narcotics, chemicals or any other types of material, or as a result of any

 

 

 

 

 

 

mental or physical condition?

(

)

Yes

(

)

No

Have you had any suit filed against you related to the practice of a profession?

(

)

Yes

(

)

No

Have you ever been convicted of a felony or misdemeanor (other than a minor traffic

 

 

 

 

 

 

violation), entered a plea of guilty or nolo contendere, entered a plea under first

 

 

 

 

 

 

offender provision? If “Yes”, attach a certified copy of the judgment rendered.

AFFIDAVIT

I Hereby swear or affirm that the answers and information contained in this section of the application are true, complete, and correct. I understand that making a false or misleading statement on this form is a crime and may result in criminal prosecution and in my being denied a registration from the Georgia State Board of Funeral Service.

STATE OF GEORGIA

 

COUNTY OF ___________________________________

______________________________________________

 

SIGNATURE OF THE APPLICANT

SUBSCRIBED AND SWORN TO BEFORE ME THIS

 

 

______________________________________________

________ DAY OF _____________________, _________

PRINT NAME

_______________________________________________

______________________________________________

NOTARY PUBLIC

DATE

MY COMMISSION EXPIRES: _____________________

 

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PART II – SUPERVISING EMBALMER

INSTRUCTIONS:

-Supervising Embalmers must have been employed as a licensed embalmer at least 3 years prior to the supervision.

-One supervisor may not supervise more than 4 apprentices.

-Supervising Embalmers must provide direct supervision, which shall mean a licensed supervisor present in the same room as apprentice during the embalming of a body.

-Trade Embalmers – Must appear before the Board and must embalm at the establishment where

the Apprentice is registered.

( ) Yes ( ) No Are you a Trade Embalmer?

When did you become licensed as an Embalmer?________________________________________________

OTHER APPRENTICES CURRENTLY SUPERVISING

NAME

REGISTRATION NUMBER

 

 

 

 

 

 

AFFIDAVIT

I, the undersigned, do hereby swear or affirm under penalty of perjury that all statements made and information contained in this application are true and correct to the best of my knowledge and belief. I understand that any willful omission or falsification of pertinent information required in the application is justification for the denial, suspension, or revocation of my registration by the Board.

STATE OF GEORGIA

 

COUNTY OF ___________________________________

______________________________________________

 

SIGNATURE OF THE SUPERVISING EMBALMER

SUBSCRIBED AND SWORN TO BEFORE ME THIS

 

 

______________________________________________

________ DAY OF _____________________, _________

PRINT NAME

_______________________________________________

______________________________________________

NOTARY PUBLIC

DATE

MY COMMISSION EXPIRES: _____________________

 

- 4 -

PART II – SUPERVISING FUNERAL DIRECTOR

INSTRUCTIONS:

-Supervising Funeral Directors must have been employed as a licensed funeral director at least 3 years prior to the supervision.

-One supervisor may not supervise more than 4 apprentices.

- Supervising Funeral Directors

must provide direct supervision, which shall mean a licensed supervisor present

in the same room as apprentice during arrangements, or conducting funeral services.

When did you become licensed as a Funeral Director?__________________________________________

OTHER APPRENTICES CURRENTLY SUPERVISING

NAME

 

REGISTRATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

AFFIDAVIT

I, the undersigned, do hereby swear or affirm under penalty of perjury that all statements made and information contained in this application are true and correct to the best of my knowledge and belief. I understand that any willful omission or falsification of pertinent information required in the application is justification for the denial, suspension, or revocation of my registration by the Board.

STATE OF GEORGIA

 

COUNTY OF ___________________________________

______________________________________________

 

SIGNATURE OF THE SUPERVISING DIRECTOR

SUBSCRIBED AND SWORN TO BEFORE ME THIS

 

 

______________________________________________

________ DAY OF _____________________, _________

PRINT NAME

_______________________________________________

______________________________________________

NOTARY PUBLIC

DATE

MY COMMISSION EXPIRES: _____________________

 

- 5 -

PART IV – CERTIFICATION OF FUNERAL ESTABLISHMENT

INSTRUCTIONS:

This section of the application must be completed and signed by the Funeral Director in Full and Continuous Charge (FDFCC) of the funeral establishment.

_________________________________________________________

______________________

PRINT NAME OF FDFCC

 

LICENSE NUMBER

_________________________________________________________

______________________

PRINT NAME OF FUNERAL ESTABLISHMENT

 

LICENSE NUMBER

___________________________________________

____________________________________________

DATE ESTABLISHMENT LICENSE WAS ISSUED

EXPIRATION DATE OF ESTABLISHMENT LICENSE

-The funeral establishment has had no violations in the last three inspections. (Rule 250-4-.06(1)(b))

-The funeral establishment has embalmed an average of at least 30 bodies per year over the preceding five years,

OR

The funeral establishment has embalmed a minimum of 150 bodies to date. (Rule 250-4-.06(1)(c))

AFFIDAVIT

I, the undersigned, do hereby swear or affirm under penalty of perjury that all statements made and information contained in this application are true and correct to the best of my knowledge and belief. I understand that any willful omission or falsification of pertinent information required in the application is justification for the denial, suspension, or revocation of my registration by the Board.

STATE OF GEORGIA

 

COUNTY OF ___________________________________

______________________________________________

 

SIGNATURE OF THE FDFCC

SUBSCRIBED AND SWORN TO BEFORE ME THIS

 

 

______________________________________________

________ DAY OF _____________________, _________

PRINT NAME

_______________________________________________

______________________________________________

NOTARY PUBLIC

DATE

MY COMMISSION EXPIRES: _____________________

 

- 6 -

PART V – AUTHORIZATION FOR BACKGROUND INVESTIGATION

I authorize the Georgia State Board of Funeral Service to conduct a background investigation of me to determine my suitability for a registration. I give my consent for full and complete disclosure of all records and information concerning myself to the Board or authorized representatives, whether such records and information are of a public, private, or confidential nature, to include criminal history records.

_____________________________________

______________

____________________________

Full Name Printed

Sex

Race

_____________________________________

 

____________________________

Social Security Number

 

Date of Birth

_____________________________________

 

____________________________

Street Address

 

Home Phone Number

_____________________________________

 

____________________________

City, State, Zip Code

 

Work Phone Number

_____________________________________

 

____________________________

Signature

 

Date

- 7 -