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 Mortician Emeritus Status License
The undersigned hereby submits this application for a mortician emeritus status license subject to the provisions of
Minnesota Statutes, section 149A.45. Include an application fee of $50 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
Date of Birth (MM/DD/YYYY)
Age
Phone Number
Mortuary Science License Number
Email Address
Signature of Applicant
Date
Except for your name and address, all of the information on this form is private until such time as the issuance of license,
after which all the information becomes public pursuant to Minnesota Statutes, section 13.41.
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
Document1
REV 04/05/2016