MORTUARY SCIENCE PRO GRAM
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3829
Fax: (651) 201-3839
Email: [email protected]
Application for Mortuary Science License to Endorse License
The undersigned hereby submits this application to practice mortuary science subject to the provisions of Minnesota Statutes, section 149A.30 and
149A.65. Include an application fee of $250 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
Email Address
Phone Number
Fax Number
MORTICIAN LICENSE INFORMATION
List additional licenses on the back if necessary.
State of Issue
Year Issued
State Regulatory Agency
State of Issue
State Regulatory Agency Phone Number
Year Issued
State Regulatory Agency
State of Issue
State Regulatory Agency
License Number
License Number
State Regulatory Agency Phone Number
Year Issued
License Number
State Regulatory Agency 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.
Signature of Applicant
Date
Along with this application, you must submit the following:
▪
Your official academic transcripts (must be mailed directly from the academic institution to MDH at the address listed above).
▪
National Board Examination results (must be mailed directly from The Conference to MDH at the address listed above).
▪
Copy of your driver’s license or State I.D.
▪
Application fee of $250 payable to: Commissioner of Finance.
▪
Submit the State Exam Application and fee.
▪
Copy of all current Mortician Licenses.
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
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REV 04/05/2016
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