M OR TU A RY S CI EN C E PR O GR AM
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3829
Fax: (651) 201-3839
Email: [email protected]
Application to Renew a License to Operate a Funeral Establishment
The undersigned hereby submits this application to renew a license to operate a funeral establishment subject to the provisions of Minnesota
Statutes, section 149A.51 and rules adopted thereunder. Include an application fee of $425 payable to: Commissioner of Finance. If postmarked
after June 30th, add a late fee of $100.
ESTABLISHMENT INFORMATION
Name of Establishment
Establishment License Number
Mailing Address
City
Establishment Address ☐ Same as mailing address
Phone Number
City
County
Email Address
State
Zip Code
State
Zip Code
Fax Number
Name of Owner(s) and percentage of ownership:
Type of Business (check one):
☐ Individual/Sole Proprietorship
☐ Partnership
☐ Private/LLC Corporation
☐ Public Corporation
☐ Cooperative
Is this establishment a corporation?
If yes, answer the rest of this section’s questions.
Place and Date of Incorporation
Federal IRS Tax Number
MN Tax I.D Number (or Owner’s Social Security Number)
Name of Corporation
Name of President
Corporation Address ☐ Same as business address above.
City
State
Zip Code
Name of Licensed Morticians and Mortician’s License Number Working at this Establishment:
INSURANCE INFORMATION
All applicants must provide proof of liability insurance coverage.
Name of Insurance Provider
Insurance Policy Number
Insurance Agent’s Name
Insurance Agent’s Phone 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.
Printed Name of Applicant
Signature of Applicant
Date
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
Document1
REV 04/05/2016