Application - Professional Licensing Boards

Wyoming State Board of Embalming
APPRENTICE EMBALMERS
Your apprenticeship period will not start until your application is submitted
to the Wyoming State Board of Embalming. Upon review and approval of the
supervising embalmer, your registration number will be issued and your
apprenticeship may begin.
It shall be the duty of the apprentice and the supervising embalmer to file the
apprentice reports with the Board office every six months. If a report is not
filed in a timely fashion, the Board may assume that you did not complete
your apprenticeship period, and no credit for the time will be given for that
six month period. However, if you do not complete a full six month period
you will be given credit for the partial period if you send in an apprenticeship
form completed up to the time that the apprenticeship ended.
No apprentice may practice as an embalmer in the State of Wyoming. The
apprentice may, however, under the immediate supervision of a licensed
embalmer, assist in the practice of embalming. The Board takes this to mean
that the supervising embalmer must at least be in the same building when the
apprentice is embalming the body. Failure to comply with this requirement
may result in penalties for both the apprentice and the embalmer.
If the apprentice has any questions about their apprenticeship, they are
instructed to contact the Board office for answers, rather than guessing that
their supervising embalmer is giving the correct answers.
Apprentice report forms will be returned to you with your apprentice
registration card. Your card is to be displayed with the embalmers license
along with their current renewal card.

LIST A
ACCEPTABLE DOCUMENTS TO ESTABLISH U.S. CITIZENSHIP
A person who is a citizen of the United States as evidenced by one of the following:
1. A copy of a birth certificate issued in or by a city, county, state, or other governmental entity within the United States or its outlying
possessions.
2. A U.S. Certificate of Birth Abroad (FS-545, DS-135) or a Report of Birth Abroad of a U.S. Citizen (FS-240).
3. A birth certificate or passport issued from:
A. Puerto Rico, on or after January 13, 1941;
B. Guam, on or after April 10, 1898;
C. U.S. Virgin Islands, on or after February 25, 1927;
D. Northern Mariana Islands, after November 4, 1986;
E. American Samoa;
F. Swain’s Island; or
G. District of Columbia.
4. A U.S. passport (expired or unexpired).
5. Certificate of Naturalization (N-550, N-57, N-578).
6. Certificate of Citizenship (N-560, N-561, N-645).
7. U.S. Citizen Identification Card (I-179, I-197).
8. An individual Fee Register Receipt (Form G-711) that shows that the person has filed an application for a New Naturalization or
Citizenship Paper (Form N-565).
9. Any other document which establishes a U.S. place of birth or indicates U.S. citizenship.
10. Copy of social security card.
LIST B
ACCEPTABLE DOCUMENTS TO ESTABLISH ALIEN STATUS
An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA) must submit supporting
documentation to establish legal presence under one of the following categories:
1. An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes:
INS Form I-551 (Alien Registration Receipt Card commonly known as a “green card”); or
Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94.
2. An alien who is granted asylum under Section 208 of the INA. Evidence includes:
INS Form I-94 annotated with stamp showing grant of asylum under Section 208 of the INA;
INS Form I-688B (Employment Authorization Card) annotated”274a.12(a)(5)”;
INS Form I-766 (Employment Authorization Document) annotated “A5";
Grant Letter from the Asylum Office of INS; or
Order of an immigration judge granting asylum.
3. A refugee admitted to the United States under Section 207 of the INA. Evidence includes:
INS Form I-94 annotated with stamp showing admission under Section 207 of the INA;
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”;
INS Form I-766 (Employment Authorization Document) annotated “A3"; or
INS Form I-571 (Refugee Travel Document).
4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA. Evidence includes:
INS Form I-94 with stamp showing admission for at least one year under Section 212(d)(5) of the INA.
5. An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect immediately prior to September 30,
1996) or Section 241(b)(3) of such Act (as amended by Section 305(a) of Division C of Public Law 104-208). Evidence includes:
INS Form I-668B (Employment Authorization Card) annotated “274a.12(a)(10)”;
INS Form I-766 (Employment Authorization Document) annotated “A10"; or
Order from an immigration judge showing deportation withheld under Section 243(h) of the INA as in effect prior to April
1, 1997, or removal withheld under Section 241(b)(3) of the INA.
6. An alien who is granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence includes:
INS Form I-94 with stamp showing admission under Section 203(a)(7) of the INA;
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3); or
INS Form I-766 (Employment Authorization Document) annotated “A3".
7. An alien who is a Cuban or Haitian entrant (as defined in Section 501(e) of the Refugee Education Assistance Act of 1980).
Evidence includes:
INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6;
Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with code CU6 or CU7; or
INS Form I-94 with stamp showing parole as “Cuban/Haitian Entrant” under Section 212(d)(5) of the INA.
8. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA. Evidence includes:
INS Form I-94 showing this status.
9. An alien who has been declared a battered alien. Evidence includes:
INS petition and supporting documentation.

Wyoming State Board of Embalming
Emerson Building, RM 104 Phone: 307-777-5403
2001 Capitol Avenue Fax: 307-777-3508
Cheyenne WY 82002
Application for Apprentice Registration
Attach a Recent
Photograph Here
Head and Shoulders Only
Please type or print clearly.
1. Name:
2. Social
Security:
Last First Middle Initial Previous Names Used
Date of
Birth:
3.
U.S. Code Title 8, Chapter 14, Section 1621 requires proof of legal presence in the United States. Attach a copy of
acceptable documentation from enclosed List A and B. Please indicate which document you are sending with the application.
 U.S. Social Security Card  U.S. Passport  State Issued Birth Certificate  Other
4. Home
Address:
Telephone Number:
( )
5. Funeral
Home:
6. Supervising
Embalmer:
7. Funeral
Home
Address:
Telephone/Fax Numbers:
( )
( )
8. Preferred Mailing Address:  Home  Business
9. E-mail Address:
10. Have you taken the International Conference of Funeral Service Examining Boards, Inc.
National Board Examination  Yes  No
Wyoming requires an overall passing grade of at least 75% .
Revised 9/13

11. EDUCATION: List the educational institutions attended or currently attending.
High School:
SCHOOL (Name and City, State) COURSE OF STUDY DATE COMPLETED
College- General Studies:
School of Embalming:
12. EXPERIENCE: List below your training/work experience within the last ten (10) years. Begin with your most
current training/work experience.
Dates: From To
Month/Year
Business:
Address:
Month/Year
Supervisor’s Name:
Brief Description of Work:
Dates: From To
Month/Year
Business:
Address:
Month/Year
Supervisor’s Name:
Brief Description of Work:
Dates: From To
Month/Year
Business:
Address:
Month/Year
Supervisor’s Name:
Brief Description of Work:
Revised 9/13

Give a brief statement explaining your interest in entering the Funeral Profession:
WARNING
Making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment
for not more than two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. 6-5-303.)
AGREEMENT
In signing this application, I do hereby state that I have read, understand, and agree to abide by the rules and regulations
promulgated by the State Board of Embalming, and W.S. 33-16-101 et. seq. I also agree to adhere to the codes of
ethics applicable to my profession and this application.
AFFIDAVIT
The undersigned deposes and says that he or she is the person making the foregoing statements and that they are made
in good faith and are true in every respect.
SIGNATURE OF APPLICANT
DATE
EMPLOYER’S STATEMENT
I certify that I have known since .
This person is Neat Courteous Industrious Punctual Loyal,
and of good moral character. I also certify that this person will not be allowed to practice the Art of Embalming without
licensed supervision as per the enclosed agreement. This person’s duties will consist of:
AFFIDAVIT
The undersigned deposes and says that he or she is the person making the foregoing statements and that they are made
in good faith and are true in every respect.
SIGNATURE OF EMPLOYER
DATE
Revised 9/13

Wyoming State Board of Embalming
Apprenticeship Supervision Agreement
Funeral Home:
Name:
Address:
City:
Supervisor
Name:
Address:
Apprentice
State: Wyoming Zip: State: Wyoming Zip:
City:
Telephone: ( 307 ) Telephone: ( 307 )
I, the above named Supervisor, agree to be the designated supervisor for the Apprentice embalmer named above, under the Rules and
Regulations of the Board of Embalming. We understand and agree to abide by the following guidelines*:
The Supervisor accepts the responsibility of the apprentice embalmer under his/her supervision. Supervision means that the Supervisor
is in the embalming room generally, and in all cases, in the funeral establishment building while the apprentice is assisting with the
preparation of the dead human body.
The Supervisor shall assume complete responsibility for all of the Apprentice’s acts and omissions within the scope of the
apprenticeship.
The Apprentice shall adhere to the Wyoming State Board of Embalming Rules and Regulations, and applicable Standards of Practice
for the profession.
The Supervisor shall semi-annually report the work which the Apprentice has performed. The report shall include the number of bodies
the apprentice has assisted in embalming or otherwise prepared for the disposition during the period.
New Apprentices who do not hold a license in another jurisdiction must complete two thousand (2,000) hours of experience, including
having embalmed twenty-five (25) dead human bodies distributed over not less than twelve (12) or more than thirty-six (36) months.
Applicants who hold a current license issued in another jurisdiction and have been continuously employed on a full-time basis for at
least one year as a licensed embalmer in that jurisdiction, shall be registered as an apprentice under a Wyoming licensed embalmer at
the time of his practical operative embalming examination which shall be performed in front of one (1) or more Board members.
The Supervisor shall not supervise the apprentice in the state of Wyoming for more than three (3) years without the Apprentice taking
the examination for an embalmer's license.
The Supervisor shall allow the Apprentice to perform independently only those functions for which the Apprentice has training and
experience.
In the event of employment termination of the Apprentice, the Supervisor shall notify the Board in writing. The Apprentice will not
provide services until they have secured employment and provided documentation of an appropriate Supervisor to the Board for
approval.
In the event of a change of the Supervisor, the Apprentice shall notify the Board in writing. The Apprentice will not provide services
until documentation of an appropriate Supervisor is approved by the Board.
Any changes in this agreement shall be submitted in writing within ten (10) days to the Board for approval.
Supervisor’s Signature
Date
Apprentice Embalmer’s Signature
Date
Approved by the Board on
Board Representative
*Refer to the current STATUTE and RULES AND REGULATIONS for additional details. Revised 9/13