CSCL/LCL-013 (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 REQUEST FOR NAME AND/OR ADDRESS UPDATE AUTHORITY: 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 CANNOT change their address, a license application for the new location must be submitted. Signature Date Approved By: Date Approved: License Number: