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Fill and Sign the Application Amp Dues Invoice Form

Fill and Sign the Application Amp Dues Invoice Form

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STATE OF MAINE DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION Board of Funeral Service 35 STATE HOUSE STATION AUGUSTA, MAINE 04333-0035 JOHN ELIAS BALDACCI ANNE L. HEAD GOVERNOR DIRECTOR SUPERVISOR APPROVAL FORM ATTACHMENT A Name of applicant: ________________________________________________________________ Type of license/registration being applied for: Attendant Practitioner Trainee Name of Funeral Establishment Employed By: ___________________________________________ Address of Funeral Establishment: ____________________________________________________ City: ___________________________ State: ____________________ Zip Code: _____________ License number of Funeral Establishment: ______________________________________________ Telephone number of Funeral Establishment: ___________________________________________ Practitioner responsible for the training/supervision of the applicant: __________________________ Practitioner’s license number: ________________________________________________________ If the above applicant is being registered as an attendant, please list the name(s) of all funeral establishments in which the attendant will be working: Name of Establishment License Number ________________________________________ _____________________ ________________________________________ _____________________ ________________________________________ _____________________ ________________________________________ _____________________ THIS SECTION TO BE SIGNED BY THE PRACTITIONER RESPONSIBLE FOR THE PRACTITIONER TRAINEE/ATTENDANT. I hereby certify that I will be responsible for the Practitioner Trainee/Attendant. Signature of Practitioner: ____________________________________________________________ Printed Name of Practitioner: __________________________________ Date: ________________ PRINTED ON RECYCLED PAPER OFFICE PHONE:(207) 624-8626 (888) 577-6690 (HEARING IMPAIRED) OFFICES LOCATED AT: 122 NORTHERN AVENUE, GARDINER, MAINE FAX: (207) 624-8637

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