Mississippi State Board of Funeral Service - Online Application for Funeral Service

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Online Application for Funeral Service

MISSISSIPPI STATE BOARD OF FUNERAL SERVICE
Application to register as a Funeral Service

* Required Fields

* Password :
(To be used for future login.)

Title

First Name

Middle Name

* Last Name

Maiden Name :

Sex:

Male Female

Address :

* Social Security Number :

Date of Birth :

yyyy-mm-dd

City, State, Zip :

County :

Home Phone :

Cell Phone :

Work Phone :

Email :

Are you a legal Resident of this State? Yes No

Mortuary Science School:

Name:

Date of Graduation:

yyyy-mm-dd

Location:

Dates Attended:
Started:

yyyy-mm-dd
Ended:

yyyy-mm-dd

		Felony
	Have you ever been convicted of a felony? No Yes If Yes explain: Give complete details as to the charge(s), date(s), place of trial, sentence, or other disposition.

Previous Experience

Have you ever held a Funeral Service, Funeral Directing, and/or Embalming License in any State?

No
Yes

If Yes,
State:
Type:
Number:

Is it in good standing?
No
Yes
If Yes give expiration date:

yyyy-mm-dd
If no give full explanation.


* Required Fields