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 Initial License to Practice Mortuary Science
The undersigned hereby submits this application to practice mortuary science subject to the provisions of Minnesota Statutes, section 149A.20 and
149A.65. Include an application fee of $200 payable to: Commissioner of Finance.
APPLICANT INFORMATION
First Name
Middle Name
Last Name
Intern #
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
EMPLOYMENT INFORMATION
Employee Name
Establishment License Number
Address
City
State
Zip Code
Email Address
Phone Number
Fax Number
List Additional Work Location(s) and Establishment License Number(s)
INTERNSHIP INFORMATION
Supervisor’s Name/Lic. No.
Establishment Name/Lic. No.
Internship Starting Date
Internship Completion Date
I certify that the information provided on this form is true and correct to the best of my knowledge and that both the applicant and the supervising
licensee fulfilled the requirements under subdivision 6. I understand that misstatement of facts may result in denial of this application.
Signature of Applicant
Date
Signature of Supervising Mortician
Date
Subscribed and sworn to on this ____day of ________________20_____.
__________________________________ Notary
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
Document1 REV 02/03/2017