If you are looking for a career in the funeral service industry, the Georgia Funeral Service Apprenticeship Form is a great way to get started. This program offers on-the-job training and allows you to work your way up through the ranks of this profession. The apprenticeship form can be used by anyone who is interested in learning more about this field and becoming a qualified professional.
| Question | Answer |
|---|---|
| Form Name | Georgia Funeral Service Apprenticeship Form |
| Form Length | 7 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 45 sec |
| Other names | funeral director apprenticeship georgia, apprenticeship forms for macon ga, georgia funeral form, georgia secretary of state funeral service |
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 |
Before filing an application for registration as a Funeral Service Apprentice, |
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please read Board Rule, Chapter |
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requirements for apprenticeship. The rule may be reviewed on our website. |
REQUIREMENTS |
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FEE |
Refer to fee listing on the application. Application fees are |
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Make payment by check or money order to Georgia State Board of Funeral |
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Service. |
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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.
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APPRENTICESHIP DETAILS |
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DATE OF |
The date your apprenticeship begins will be determined by the date your |
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REGISTRATION: |
application is approved by the Board. The Board will approve your |
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application only when it is completed. It is imperative that you the |
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applicant review your application prior to submitting it to the Board office, |
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as incomplete applications will result in unnecessary delays in the approval |
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of the applications. |
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HOURS: |
3120 hours(the equivalent of 18 months of |
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DURATION: |
A minimum of 18 months. The apprenticeship registration, which is valid |
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for two years, may be renewed twice. The apprenticeship time is in |
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addition to the time required to graduate from a college of funeral service or |
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other college. |
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SUPERVISION: |
An apprentice must serve at a |
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REPORTS: |
An apprentice must complete report forms which may be obtained from the |
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Board office or on the Board website. It is the responsibility of the |
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apprentice to maintain records of service. |
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CHANGES: |
An apprenticeship is approved for a specific establishment and under a |
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specific supervising embalmer, funeral director, or both. Any change shall |
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terminate the apprenticeship immediately. You must then submit a new |
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application, which must be presented to the Board for approval. Reports |
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must be kept current and must be available for review by the Board |
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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 |
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Initial Funeral Service Apprenticeship |
$ |
40.00 |
Non Refundable |
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Change in Apprenticeship Site(to include change of supervisors) |
$ |
20.00 |
Non Refundable |
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Change in Supervising Embalmer&/Or Funeral Director Only |
$ |
20.00 Non Refundable |
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Reinstatement of Apprenticeship Registration # ___________ |
$180.00 |
Non Refundable |
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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. §
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 |
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__________ |
__________ |
__________ |
__________ |
HEIGHT |
WEIGHT |
EYES |
HAIR |
APPRENTICESHIP SITE INFORMATION
________________________________________________________________________ |
________________________________ |
FUNERAL ESTABLISHMENT NAME |
LICENSE NUMBER |
________________________________________________________________________ |
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SUPERVISING DIRECTOR |
LICENSE NUMBER |
________________________________________________________________________ |
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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.
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Yes |
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No |
Are you currently registered as an Apprentice? |
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If “Yes,” please provide your Apprentice Registration Number:________________ |
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Yes |
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No |
Have you ever been registered you as an Apprentice in this state? |
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If “Yes,” please provide your Apprentice Registration Number:________________ |
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Yes |
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No |
Are you a high school graduate, or have you obtained a GED Certificate? |
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You must attach a copy of your diploma or GED certificate to this application. |
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Yes |
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No |
Do you now hold, or have you in the past held, a professional license in any state? |
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If “Yes”, submit an original notarized letter from the state of licensure. |
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Yes |
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No |
Have you had revoked or suspended or otherwise sanctioned any license issued to you |
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by any board or agency in Georgia or any other state? |
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Yes |
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No |
Were you denied issuance of or, pursuant to any disciplinary proceedings, refused |
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renewal of a license by any board or agency in Georgia or any other state? |
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Yes |
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No |
Have you knowingly failed to renew a license during an investigation or disciplinary |
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action? |
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Yes |
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No |
Have you been subject to disciplinary action or had your membership revoked by a |
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professional organization governing the practice of that profession? |
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Yes |
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No |
To the best of your knowledge, is there any disciplinary action pending against you by |
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any licensing board or professional organization? |
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Yes |
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No |
Have your been arrested, charged or sentenced for the commission of a felony or any |
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crime involving moral turpitude? |
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Yes |
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No |
Are you unable to practice with reasonable skill and safety due to illness or use of |
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alcohol, drugs, narcotics, chemicals or any other types of material, or as a result of any |
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mental or physical condition? |
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Yes |
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No |
Have you had any suit filed against you related to the practice of a profession? |
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Yes |
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No |
Have you ever been convicted of a felony or misdemeanor (other than a minor traffic |
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violation), entered a plea of guilty or nolo contendere, entered a plea under first |
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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 |
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COUNTY OF ___________________________________ |
______________________________________________ |
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SIGNATURE OF THE APPLICANT |
SUBSCRIBED AND SWORN TO BEFORE ME THIS |
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______________________________________________ |
________ 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 |
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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 |
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COUNTY OF ___________________________________ |
______________________________________________ |
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SIGNATURE OF THE SUPERVISING EMBALMER |
SUBSCRIBED AND SWORN TO BEFORE ME THIS |
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______________________________________________ |
________ DAY OF _____________________, _________ |
PRINT NAME |
_______________________________________________ |
______________________________________________ |
NOTARY PUBLIC |
DATE |
MY COMMISSION EXPIRES: _____________________ |
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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 |
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in the same room as apprentice during arrangements, or conducting funeral services. |
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When did you become licensed as a Funeral Director?__________________________________________ |
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OTHER APPRENTICES CURRENTLY SUPERVISING |
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NAME |
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REGISTRATION NUMBER |
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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 |
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COUNTY OF ___________________________________ |
______________________________________________ |
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SIGNATURE OF THE SUPERVISING DIRECTOR |
SUBSCRIBED AND SWORN TO BEFORE ME THIS |
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______________________________________________ |
________ DAY OF _____________________, _________ |
PRINT NAME |
_______________________________________________ |
______________________________________________ |
NOTARY PUBLIC |
DATE |
MY COMMISSION EXPIRES: _____________________ |
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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.
_________________________________________________________ |
______________________ |
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PRINT NAME OF FDFCC |
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LICENSE NUMBER |
_________________________________________________________ |
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PRINT NAME OF FUNERAL ESTABLISHMENT |
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LICENSE NUMBER |
___________________________________________ |
____________________________________________ |
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DATE ESTABLISHMENT LICENSE WAS ISSUED |
EXPIRATION DATE OF ESTABLISHMENT LICENSE |
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OR
The funeral establishment has embalmed a minimum of 150 bodies to date. (Rule
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 |
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COUNTY OF ___________________________________ |
______________________________________________ |
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SIGNATURE OF THE FDFCC |
SUBSCRIBED AND SWORN TO BEFORE ME THIS |
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______________________________________________ |
________ DAY OF _____________________, _________ |
PRINT NAME |
_______________________________________________ |
______________________________________________ |
NOTARY PUBLIC |
DATE |
MY COMMISSION EXPIRES: _____________________ |
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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.
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____________________________ |
Full Name Printed |
Sex |
Race |
_____________________________________ |
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____________________________ |
Social Security Number |
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Date of Birth |
_____________________________________ |
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____________________________ |
Street Address |
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Home Phone Number |
_____________________________________ |
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City, State, Zip Code |
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Work Phone Number |
_____________________________________ |
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____________________________ |
Signature |
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Date |
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