Free 18558.FH11 - Indiana

APPLICATION FOR RECOGNITION AS A SPONSOR OF CONTINUING EDUCATION
State Form 18558 (R3 / 6-03)

STATE BOARD OF FUNERAL AND CEMETERY SERVICE 302 WEST WASHINGTON STREET, ROOM E034 INDIANAPOLIS, INDIANA 46204-2700 TELEPHONE: (317) 232-2980

Full name Business address (number and street) Contact person City State T elephone number ZIP code

1. We plan to offer Continuing Education Programs to licensees under the continuing education rules of the Indiana State Board of Funeral and Cemetery Service, hereafter referred to as the "board", and request recognition as a sponsor. We are (check one ): a. an accredited university or college b. a national or state funeral service program c. school of mortuary science d. "Other" (specify ) Organizations applying must submit a complete description of their programs together with any documents which will aid the board in making a determination as to the acceptability of the sponsor. You must also submit to the board the proposed amount of credit to be given for each of your programs. 2. We plan to offer continuing education in one or more of the following subject areas: a. Business administration b. Religion c. Natural Sciences d. Management Services systems, cost, budget, merger and acquisition, data processing, etc. e. Pre-Need Services 3. In order to comply with the requirements of the board, we agree that: a. The course will be given by a board recognized sponsor and is individually approved by the board. A course will not qualify unless the course and the sponsor have both been approved by the board prior to the time it is conducted. b. An outline of the course is prepared and distributed to attendees. The outline shall state the number of applicable continuing education hours. c. The course is at least one instructional hour of fifty (50) minutes in length. d. The course is conducted by a qualified instructor. e. The course is not given during meals. 4. After board approval, as a sponsor of continuing education courses, we agree to meet the following requirements on a continuing basis: a. Keep an accurate record of course attendance showing date, place, name of attendee, and their state board license number. b. Maintain a copy of the course outline and the attendance records pertaining thereto for four (4) years following presentation of the courses by the sponsor. c. Upon request, provide each funeral director and embalmer who attended the course a verification of attendance which shall state the date of the course, the subject of the course, and the number of continuing education hours. The board shall approve sponsors and their individual continuing education courses. The board reserves the right to withdraw such approval for good cause. 5. We understand that if this application is approved, said approval shall be effective the month in which it is approved. I (we) hereby certify, under penalty of perjury, that the information submitted herewith is in compliance with the Indiana State Board of Funeral and Cemetery Service Rules and Regulations and is true and correct to the best of my (our) knowledge and belief.
Signature of applicant Printed or typed name of applicant

f. Restorative art / embalming g. Indiana law pertaining to funeral service h. Funeral service counseling i. Funeral service merchandising j. Funeral customs k. Sanitation and health control

OFFICE USE ONLY

COMMENTS: OFFICE USE ONLY

Rejected this

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Approved this

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