NUMBER OF FUNERAL HOME LOCATIONS

If you are an individual funeral home with a single location, please select the Single Location radio button below.

If you have several funeral home locations, you have the option to either:

a.) Combine all locations into one membership (with a combined case count used for dues calculation). If you prefer this option, please select the Multiple Locations radio button below.

OR

b.) Maintain individual memberships for each location (with separate case counts for each location used for dues calculation). If you prefer this option, please select the Single Location radio button below. With this option, it will be necessary for you to complete an application for each funeral home location.

If you opt to combine all locations (and case counts) into one membership, this will affect the number of paid firms when it comes to PFDA delegate count.

Please indicated the type of membership, by selecting the appropriate radio button. If you select the Multiple Locations options, additional form fields will appear to allow you to provide funeral home information for all locations.

* Select number of funeral home locations:
Single Location - individual funeral home
Multiple Location - several funeral homes with combined case count

FUNERAL HOME INFORMATION

* Legal Name of Funeral Home (complete licensed name):

* Funeral Home License Number:

* Common Name Used (ex. Smith Funeral Home as common name used for John Q. Smith Funeral Home, the legal name):

* Main Contact Person - for PFDA correspondence and publications (contact does not have to be Supervisor):

* Contact's E-Mail Address:

Would you like to receive PFDA Newsletter via E-Mail? Check this box, if you would like the Main Contact Person to receive the newsletter via E-Mail. If the box is left unchecked, the newsletter will be mailed.

* Funeral Home Street Address:

* City:

* State:

* Zip:

* County:

* Telephone Number (include area code):

* Fax Number (include area code):

Funeral Home Website URL (example: www.smithfuneral.com):

ADDITIONAL NEWSLETTER SUBSCRIPTION
Your PFDA membership entitles you to one (1) subscription to The Reporter newsletter, which will be sent to the person designated as the Main Contact Person. If you would like to have additional subscriptions, please contact PFDA for more information.

EMPLOYEE INFORMATION

In order for employees to be able to participate in PFDA events and continuing education programs, their information must be included with your application. Please provide the names and license numbers of all licensed funeral director employees.

* Name of Supervisor:

* License # of Supervisor:

Employee #1 - Full Name:

Employee #1 - License Number:

Employee #2 - Full Name:

Employee #2 - License Number:

Employee #3 - Full Name:

Employee #3 - License Number:

Employee #4 - Full Name:

Employee #4 - License Number:

SELECT NUMBER OF CASES AND LOCAL AREA

Please select the TOTAL number of cases per year from the first drop down menu box.

Once you have selected the number of cases, another drop down menu box will appear for you to select your LOCAL area. If you do not know which Local area your county is located in, click here to view a map.

* Select TOTAL Number of Cases from Drop Down Menu:

* Select LOCAL Area for Funeral Home Location from Drop Down Menu:

Select LOCAL Area for Funeral Home Branch Location #1 from Drop Down Menu:

Select LOCAL Area for Funeral Home Branch Location #2 from Drop Down Menu:

* Select LOCAL Area for Funeral Home Location from Drop Down Menu:

Select LOCAL Area for Funeral Home Branch Location #1 from Drop Down Menu:

Select LOCAL Area for Funeral Home Branch Location #2 from Drop Down Menu:

Select LOCAL Area for Branch #2 Location:

Select LOCAL Area for Funeral Home Branch Location #2 from Drop Down Menu:

By submitting this form, I hereby certify that the information about the number of cases per year is true and accurate.

PFDA'S FUNERAL SERVICE ACTION FUND CONTRIBUTION

(If you do not wish to contribute to the Service Action Fund, leave these next two fields blank.)

Yes, I want to contribute towards protecting my funeral license from unlicensed practices, by contributing to the Service Action Fund.

Enter Contribution Amount:

NOTICE REGARDING TAX DEDUCTIBILITY OF DUES:
12% of dues for PFDA, are not deductible in accordance with IRS Sec. 6033. Payment of dues, contributions or gifts to PFDA are not deductible as charitable contributions for federal income tax purposes, but may be deductible under other sections of the Internal Revenue Code.

SUBMIT MEMBER INFO & PROCEED TO CHECKOUT
Only click the Submit button ONCE. It may take a few moments for the form to process. If it has been successful, you will be directed to the Order Confirmation page.

MEMBERSHIP RENEWAL

NEW MEMBER APPLICATION

NUMBER OF FUNERAL HOME LOCATIONS

FUNERAL HOME INFORMATION

EMPLOYEE INFORMATION

SELECT NUMBER OF CASES AND LOCAL AREA

PFDA'S FUNERAL SERVICE ACTION FUND CONTRIBUTION