Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 12 - Board of Funeral Directors and Embalmers › Article 2 - LICENSING PROVISIONS › Section R4-12-204 - Application for a Funeral Establishment License or Interim Funeral Establishment Permit

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant
				for a funeral establishment license shall submit an application packet to the
				Board that contains the fee required by the Board, information required in
				A.R.S. §
									32-1383,
				and an application form that contains:
1. The
				funeral establishment's current and previous name, if any;
2. The address of the physical location and
				telephone number of the funeral establishment;
3. The responsible funeral director's name
				and license number;
4. The name of
				the funeral establishment's current and previous owner;
5. Whether the funeral establishment is a
				proprietorship, a corporation, a partnership, a limited liability company, or a
				subsidiary of a corporation, a partnership, or a limited liability
				company;
6. If the previous owner
				was a corporation, the name of the corporation;
7. The name and address of each person owning
				10 percent or more of the establishment or corporation common stock;
8. If a corporation, partnership, or limited
				liability company:
a. The state and date of
				incorporation or formation;
b. The
				name and address of the Arizona statutory agent or agent appointed to receive
				process; and
c. The name, address,
				and title of each officer, director, general partner, or member;
9. Whether the applicant has ever
				been convicted of or entered into a plea of no contest to a class 1 or 2
				felony, including the information in subsections (A)(10)(a) through
				(A)(10)(f);
10. Whether the
				applicant, within five years from the date of the application, has been
				convicted of or entered into a plea of no contest to a felony or to a
				misdemeanor that is reasonably related to the applicant's proposed area of
				licensure including the:
a. Charged felony or
				misdemeanor;
b. Date of
				conviction;
c. Court having
				jurisdiction over the felony or misdemeanor;
d. Probation officer's name, address, and
				telephone number, if applicable;
e.
				A copy of the notice of expungement, if applicable; and
f. A copy of the notice of restoration of
				civil rights, if applicable;
11. Whether the applicant, within five years
				from the date of the application, has committed any act involving dishonesty,
				fraud, misrepresentation, breach of fiduciary duty, gross negligence, or
				incompetence reasonably related to the applicant's proposed area of
				licensure;
12. Whether the
				applicant is currently incarcerated or on community supervision after a period
				of imprisonment in a local, state, or federal penal institution or on criminal
				probation;
13. Whether the
				applicant, within five years from the date of the application, has had an
				application for a license, registration, certificate, or endorsement denied or
				rejected by any state funeral licensing authority including the:
a. Reason for the denial or
				rejection,
b. Date of the denial or
				rejection, and
c. Name and address
				of the agency that denied or rejected the application;
14. Whether the applicant has, within five
				years from the date of the application, had a license, registration,
				certificate, or endorsement suspended or revoked by any state funeral licensing
				authority including the:
a. Reason for the
				suspension or revocation,
b. Date
				of the suspension or revocation, and
c. Name and address of the state licensing
				authority that suspended or revoked the license;
15. Whether the applicant has ever
				surrendered a license, registration, certificate, or endorsement to the Board
				or any state funeral licensing authority;
16. A statement, signed by the responsible
				funeral director and notarized, affirming licensure in Arizona and confirming
				responsibility for the funeral establishment's compliance with Arizona state
				laws and rules; and
17. The
				applicant's signature.