Online Form - Application for New/Renewal of Funeral Director’s Licence

Applicant Details

Title*

MrMrsMsDr

Surname*

First Name(s)*

Trading Name(s) of Business*

Business Address*

Postcode*

Number of years the applicant has held a Funeral Director’s Licence*

Have you ever been convicted of any offence, anywhere?*

YesNo

If “Yes” provide details

Email Address*

Home Phone Number

Work Phone Number

Mobile Phone Number

Full name of applicant*

Date*

Director(s) Details

Title*

MrMrsMsDr

Surname*

First Name(s)*

Postal Address*

Postcode*

Full name*

Date*

Manager(s) Details

Title*

MrMrsMsDr

Surname*

First Name(s)*

Postal Address*

Postcode*

Full name*

Date*

Secretary Details

Title*

MrMrsMsDr

Surname*

First Name(s)*

Postal Address*

Postcode*

Full name*

Date*

Partners Details

Title*

MrMrsMsDr

Surname*

First Name(s)*

Postal Address*

Postcode*

Full name*

Date*

I hereby certify that the Board’s standard requirements appropriate to this application as contained in the Policy for Licensing of Funeral Directors have been met.
I agree to maintain Public Liability Insurance cover and Workers Compensation Insurance cover (where applicable) as a condition of my license.

A Copy Certificate of Currency of Third Party Insurance must be attached to this application

I agree to provide details of these insurance policies annually.
I am familiar with the Cemeteries Act and the Town of Port Hedland Cemeteries Local Law and agree to abide by the requirements as set out.
Should these requirements not be met I understand that I am liable to incur penalties and/or the loss of my Funeral Directors Licence, subject to my right of appeal.

Capacity Of Applicant

Title*

MrMrsMsDr

Surname*

First Name(s)*

Capacity*

Postal Address*

Postcode*

Full name*

Date*

Insurance Details

Insurance Company Name (Public Liability)*

Policy Number*

Expiry Date*

Insurance Company Name (Worker's Compensation)*

Policy Number*

Expiry Date*

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