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DETAILED LICENSE VERIFICATION AUTHORITY: R 339.301 & 1979 PA 152 PENALTY: FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN DENIAL OF THE APPLICATION AND/OR DISCIPLINARY ACTION. Name License Number Phone Number E-Mail Address Name and Address to Mail License Verification 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 Mortuary Science - Courtesy License FEE PAYMENT INFORMATION - $15.00 for each request. Please submit a separate form for each request. LICENSE TYPE For Funeral Home: Please Check Box for Information Requested Other Make your check or money order in U.S. Currency payable to: STATE OF MICHIGAN FOR OFFICE USE ONLY 4503-51 4502-51 4501-51 FEES ARE AUTHORIZED UNDER 1979 PA 152 & R339.301 AND ARE NOT REFUNDABLE. Approved By: Date Approved: License Number CSCL/LCE-801 (10/19) Page 1 of 1 Corporations, Securities & Commercial Licensing Licensing Division P.O. Box 30018, Lansing, MI 48909 517-241-9221 www.michigan.gov/mortuaryscience Business Owner Opening & Closing Dates
