MORTUARY SCIENCE
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3861
Fax: (651) 201-3839
Email: [email protected]
Application to Renew a Mortician License
The undersigned hereby makes application to renew a license to practice mortuary science subject to the provisions of Minnesota Statutes,
Chapter 149A. To renew your license to practice mortuary science, complete this application and mail to the address above with the $200 renewal
fee. Make checks payable to: Treasurer, State of Minnesota.
Current licenses expire on December 31. Renewal form and fee due by December 31. If postmarked after December 31 add a late fee of $100.00.
Automatic lapse date is 31 calendar days after expiration date.
PERSONAL INFORMATION
First Name
Middle Name
Mailing Address
County
Last Name
Mortician License Number
City
State
Phone Number
Zip Code
Email Address
EMPLOYMENT STATUS
Select only one of the choices below.
☐ Full-time employment in funeral service.
☐ Funeral industry sales/service (casket, vault, fluid, insurance, cemetery, etc.).
☐ Part-time employment in funeral service.
☐ Pre-need sales only.
☐ Retired working part-time in funeral service.
☐ Funeral industry educator/regulator.
☐ Retired.
☐ Not working in funeral service.
EMPLOYMENT INFORMATION
Identify name of Minnesota funeral establishment (if any) where you are currently employed.
Name
Establishment License Number
Mailing Address
City
Phone Number
Fax Number
State
Zip Code
CONTINUING EDUCATION REQUIREMENT
Licensees whose license ends in an odd number must complete CE hours at renewal time (Before
January 1, every odd year). If a licensee's license ends in an even number, the licensee must complete
the licensee's CE hours at renewal time (before January 1, every even year).
You must mail your CE Report Form and supporting documents with this application.
*Failure to complete your CE's in your reporting time frame may result in a penalty.
I have accumulated and submitted 15 or more
CEU’s during the reporting period.
☐ Yes
☐ No (check one)
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 of Signature
Please mail my license to (check one): ☐ My mailing address.
☐ The funeral establishment where I work.
If you require an alternate format (i.e., large print), please call (651) 201-3829.
L:\MORTSCI\FORMS\Applications\mortrenewalapp.docx
Rev. 02/2017