Items one (1) through four (4) are contained in K.S.A. 65-1766 which states that the Kansas State Board of Mortuary Arts may refuse to issue or renew a license or revoke or suspend a license for the crematory, upon a finding that the crematory operator in charge:

1.  has been convicted of a felony or an offense of moral turpitude, and has not demonstrated to the board's satisfaction that such crematory operator in charge has been sufficiently rehabilitated to warrant the public trust;
2.  has violated any law, ordinance or rule and regulation affecting the handling, custody, care or transportation of dead human bodies or cremated remains;
3.  has failed to report to the board any adverse action taken against the crematory operator in charge or the crematory by another state or licensing jurisdiction, professional association or society, governmental agency, law enforcement agency or a court, and/or
4.  has had a license to operate a crematory revoked or suspended, or had other action taken against oneself or had an application for a license denied by the proper licensing authority of another state, territory, District of Columbia or other country.

5.  if you are you aware of any pending charges filed or in the process of being filed against you relating to any of the above situations.

    As used in this section, “license” means a crematory license, which is issued to a crematory operator who will be in charge of the crematory.  Pursuant to KSA 65-1762, the crematory operator in charge of a licensed crematory must hold a Kansas funeral director’s or embalmer’s license unless the crematory only receives dead human bodies for cremation through licensed funeral establishments or branch funeral establishments.

              If you are applying for renewal of a license, check this line if any of the above situations have occurred within the past two (2) year licensing period. If you are applying for a license for the first time, or re-applying for a license that expired or lapsed, or are applying for reinstatement of a license, check this line if any of the above situations have ever occurred.  If submitting this renewal or application prior to your individual renewal or licensure eligibility date, it remains your responsibility to notify the board should any of the above mentioned situations occur during the time frame in which this document is submitted and up until/including your renewal due date or licensure eligibility date.

    I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.

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  Signature of Crematory Operator in Charge             County                          Social Security Number                  Date

REMEMBER: To include documentation (including proof of rehabilitation) if you have checked the above line.

K.S.A. 74-139 states that upon request of the director of taxation, the board is required to provide a listing of all applicants, their social security number and address.

Failure to date and sign this document will result with the board being unable to complete processing of this renewal/application.