Home Assumption Of Responsibility Funeral Director (Funeral Establishment) Assumption of Responsibility - Funeral Director (Funeral Establishment) A.R.S §32-1333 A Responsible Funeral Director must notify the Board in writing within five business days after a change in employment, excluding Saturdays, Sundays and other legal holidays. Funeral Establishment Name of Funeral Establishment License Number Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Business Email of Record Funeral Director Previous Responsible Funeral Directors First Name Previous Responsible Funeral Directors Last Name New Responsible Funeral Directors First Name New Responsible Funeral Directors Last Name Home Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Email You will need to confirm your submission through this email. License Number Update Point of Contact Email Address Yes No New Point of Contact email - All Board notifications will go to this email address NOTE: There can only be one POC email address and all Board notifications will be sent to the designated POC only Effective Date I hereby affirm that I am duly licensed as a funeral director in the State of Arizona and reside therein. I am familiar with the laws of Arizona and the rules and regulations of the Arizona State Board of Funeral Directors and Embalmers as well as the Department of Health Services as it relates to funeral establishments. I affirm that the establishment will be equipped, operated and maintained in accordance with the provisions of such laws and regulations. A.R.S. § 32-1382.A.3. “A funeral establishment licensed pursuant to this article shall: Employ and designate a responsible funeral director to manage and supervise the daily operation of the funeral establishment. The responsible funeral director is responsible for the funeral establishment complying with the laws of this state and the rules of the board. The establishment or the responsible funeral director shall designate a licensed funeral director to act as an interim responsible funeral director”. As responsible funeral director, I understand that I am responsible to the Arizona State Board of Funeral Directors and Embalmers for a licensed funeral establishment to be in compliance with the aforementioned laws and regulations and hereby accept responsibility for the establishment named above. I agree - I understand that by signing, my electronic signature is the legal equivalent of my handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. Under penalty of perjury, I herewith affirm that my electronic signature was signed by myself with my full knowledge and consent. Signature Sign above Submit Leave this field blank