Minnesota Registration & Certification System (MR&C)
Funeral Director or Funeral Home Staff
User Agreement
Funeral Establishment Owner
☐ Add
First Name
MI
Email
☐ Change
☐ Delete
Last Name
License Number
Phone
Funeral Establishment
Funeral Establishment License Number(s)
Address
I authorize the staff named below to enter fact of death information into MR&C.
Signature
Date
By signing this application I agree that I will not compromise the security of MR&C by sharing my password or logging into MR&C with any
user ID other than my own. I understand that penalties for unlawful use of data exist under Minnesota Statutes 609.87-609.98 and Chapter
13. Failing to comply with this agreement may result in my access to MR&C being terminated.
Funeral Director or Funeral Home Staff (Funeral Director must provide License Number)
☐ Add
☐ Change
☐ Delete
First Name
License Number
MI
Last Name
Email
Phone
By signing this application I agree that:

I will not compromise the security of MR&C by sharing my password or logging into MR&C with any user ID other than my own.

I understand that penalties for unlawful use of data exist under Minnesota Statutes 609.87-609.98 and Chapter 13.

Failing to comply with this agreement may result in my access to MR&C being terminated.
Signature
Date
Funeral Director or Funeral Home Staff (Funeral Director must provide License Number)
☐ Add
☐ Change
☐ Delete
First Name
License Number
MI
Last Name
Email
Phone
By signing this application I agree that:

I will not compromise the security of MR&C by sharing my password or logging into MR&C with any user ID other than my own.

I understand that penalties for unlawful use of data exist under Minnesota Statutes 609.87-609.98 and Chapter 13.

Failing to comply with this agreement may result in my access to MR&C being terminated.
Signature
Date
Funeral Director or Funeral Home Staff (Funeral Director must provide License Number)
☐ Add
☐ Change
☐ Delete
First Name
License Number
Email
MI
Last Name
Phone
By signing this application I agree that:

I will not compromise the security of MR&C by sharing my password or logging into MR&C with any user ID other than my own.

I understand that penalties for unlawful use of data exist under Minnesota Statutes 609.87-609.98 and Chapter 13.

Failing to comply with this agreement may result in my access to MR&C being terminated.
Signature
Date
Submit completed form by:
Email: [email protected]
Fax: 651-201-5750
Retain a copy of the completed form for your records.
rev 4/2017