MORTUARY SCIENCE PRO GRAM
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3829
Fax: (651) 201-3839
Email: [email protected]
Mortuary Science Internship Registration
The undersigned hereby submits this application to serve an internship in mortuary science subject to the provisions of Minnesota Statutes, section
149A.20 and 149A.65. Include all documents listed at the bottom of this application and an application fee of $75 payable to: Commissioner
of Finance.
APPLICANT INFORMATION
First Name
Middle Name
Last Name
Home Address
City
State
Zip Code
County
Mailing Address ☐ Same as home address.
City
State
Zip Code
County
Social Security Number (Required pursuant to Minnesota Statutes, section 270.72.)
Date of Birth (MM/DD/YYYY)
Age
APPLICANT CONTACT INFORMATION
Personal Email Address
Work Email Address
Phone Number
Fax Number
INTERNSHIP INFORMATION
Identify where your internship will be served.
Name of Establishment
Establishment Lic. No.
Anticipated Starting Date of Internship
Name of Mortician Supervising Applicant’s Internship
Supervisor’s Lic. No.
Business Address
City
State
Zip Code
Mailing Address ☐ Same as business address.
City
State
Zip Code
Email Address
Phone Number
Fax Number
I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that misstatement of facts may
result in denial of this application.
Signature of Applicant
Date
Along with this application, you must submit the following:
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Your official academic transcripts (must be in a sealed unopened envelope. Must have 120 semester credits or 180 quarter credits.)
National Board Examination results (must be in a sealed unopened envelope.)
Copy of your driver’s license or State I.D.
Submit the State Exam Application and fee of $125.
Application fee of $75 payable to: Commissioner of Finance.
*Failure to submit all documents together will result in your application being mailed back to you.
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
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REV 04/11/2017