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: