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Online Form - Funeral Director’s Licence Application

Cemeteries Act 1986

Use this form to apply for a new, or to renew an existing annual Funeral Directors Licence

Please review the following, prior to submitting your application:

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You have the ability to save this form and complete it at a later date. An email will be generated and sent to the specified address.

Email Address:

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Note: Incomplete forms are kept for a period of 2 day(s) , after this time the system will automatically delete your response.

Applicant Details

Application Type *

New ApplicationRenewal of Licence

Full Name of Person Completing This Application *

Contact Number - BUSINESS *

Contact Number - MOBILE

Email *

Business Information

Business Name *

Business ABN *

Business Type *

If other, What type of business

Business Address

Street Address:

City:

State:

Post Code:

Country:

Business Phone Number *

Postal Address

Street Address:

City:

State:

Post Code:

Country:

Full Name - DIRECTOR/PARTNER 1 *

Address - DIRECTOR/PARTNER 1

Street Address:

City:

State:

Post Code:

Country:

Full Name - DIRECTOR/PARTNER 2

Address - DIRECTOR/PARTNER 2

Street Address:

City:

State:

Post Code:

Country:

Please provide name and address details for any additional DIRECTORS/PARTNERS

Full Name - MANAGER (if different from above)

Address - MANAGER (if different from above)

Street Address:

City:

State:

Post Code:

Country:

Full Name and Address of Additional MANAGER/S

Funeral Director Licence Information

Annual Licence Period (start date will be from date of the Council decision within the relevant licence year period) *

Number of years Applicant has held a Funeral Directors Licence *

Have any of the applicants been convicted of any offence, anywhere?

YesNo

Have all applicants got a National Police Clearance (issued within the last 6 months)?

YesNo

Have any of the applicants ever been declared bankrupt or placed in receivership?

YesNo

Attachments

Please attach documentation that will assist the Shire in determining that you meet the requirements of Section 17(2) of the Cemeteries Act, 1986.

Please upload a letter outlining how you meet the boards requirements that your business is
(a) Is of good reputation and is fit to hold a funeral director’s licence; and
(b) Has suitable facilities and equipment for handling and storing deceased persons and conducting funerals.

Please upload National Police Clearance Certificate/s issued within the last 6 months?

Please provide your Certificate/s of Currency for any applicable insurances held *

Please provide at least 1 Character Reference and 2 Professional References to support your application
(a) References must not be older than 6 months
(b) The referee must not be a relative, a proposed or current business partner, or an employee of the applicant
(c) References should be as detailed as possible but include only information relevant to the applicants suitability to hold a funeral director's licence.

Please upload any other attachments to support this application here

Certification by Applicant

I have read and understood the 'Conditions of Issue', 'Shire of Wyndham East Kimberley Cemeteries Local Law 2003' & 'Cemeteries Act, Division 3'

YesNo

I agree to: *

Maintain Public Liability Insurance cover and Workers Compensation Insurance Cover (where applicable) as a condition of my licence.

I understand: *

That I am required to provide updated Certificates of Currency for all policies should they lapse during the licenced period.

I Confirm: *

That all persons named in this application are aware of application and consent to this application being made.

I Understand: *

That this licence may be cancelled or suspended by the Shire at any time, subject to my right of appeal.

Please type your name below to signify that you agree that all information given above is true and correct at the time of submission *

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