request for name and or address update - michigan...mortuary science - funeral director/trainee...
Post on 20-Aug-2020
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CSCL/LCL-013 (10/19)Page 1 of 1
Corporations, Securities & Commercial Licensing Licensing Division
P.O. Box 30018, Lansing, MI 48909517-241-9221
www.michigan.gov/mortuaryscience
REQUEST FOR NAME AND/OR ADDRESS UPDATEAUTHORITY: 2004 PA 403 & 1980 PA 299
PENALTY: FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN DENIAL OF THE APPLICATION AND/OR DISCIPLINARY ACTION.
Name on Current License (including d/b/a, if applicable) License Number
New Name Requested (including d/b/a, if applicable)
New Address Requested
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.
Mortuary Science - Funeral Director/Trainee
Mortuary Science - Funeral Homes*
(name change only)
Mortuary Science - Courtesy License
FEE PAYMENT INFORMATION - $10.00 for each request.
LICENSE TYPE - CHECK ALL THAT APPLY
Make your check or money order in U.S. Currency payable to:
STATE OF MICHIGAN
FEES ARE AUTHORIZED UNDER 2004 PA 403 & 1980 PA 299 AND ARE NOT REFUNDABLE
FOR OFFICE USE ONLY
City, State and Zip Code
Phone Email Address
4503-32
4502-32
4501-32
*Locations which require an inspection CANNOTchange their address, a license application for thenew location must be submitted.
Signature Date
Approved By: Date Approved:
License Number:
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