DCI | Missouri Division of Professional Registration

Name as it appears on your certificate

First Name: *

Middle Initial:

Last Name: *

Email: *

Check this box if you wish to update your email address on file with the board

License Type:

Funeral Director

Funeral Director Limited

Embalmer

Preneed Agent

Preneed Agent Funeral Director

Funeral Establishment

Preneed Provider

Preneed Seller

Funeral Director

License Number: *

Reason for Request: *

Add location

Change of location

License was damaged

License was lost

Other

Explanation: *

Funeral Director Add Location

If you have added location(s) please list the name(s) and license number(s) of where you are now employed.

Establishment 1:

Funeral Establishment Name:

License Number:

Establishment 2:

Funeral Establishment Name:

License Number:

Establishment 3:

Funeral Establishment Name:

License Number:

Establishment 4:

Funeral Establishment Name:

License Number:

Funeral Director Changed / Removed Location

If you have changed/removed location(s) please list the name(s) and license number(s) of where you no longer work.

Establishment 1:

Funeral Establishment Name:

License Number:

Establishment 2:

Funeral Establishment Name:

License Number:

Establishment 3:

Funeral Establishment Name:

License Number:

Establishment 4:

Funeral Establishment Name:

License Number:

Comment(s):

Funeral Director Limited

License Number: *

Reason for Request: *

Add location

Change of location

License was damaged

License was lost

Other

Explanation: *

Funeral Director Limited Add Location

If you have added location(s) please list the name(s) and license number(s) of where you are now employed.

Establishment 1:

Funeral Establishment Name:

License Number:

Establishment 2:

Funeral Establishment Name:

License Number:

Establishment 3:

Funeral Establishment Name:

License Number:

Establishment 4:

Funeral Establishment Name:

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License Number:

Funeral Director Limited Changed / Removed Location

If you have changed/removed location(s) please list the name(s) and license number(s) of where you no longer work.

Establishment 1:

Funeral Establishment Name:

License Number:

Establishment 2:

Funeral Establishment Name:

License Number:

Establishment 3:

Funeral Establishment Name:

License Number:

Establishment 4:

Funeral Establishment Name:

License Number:

Comment(s):

Embalmers

License Number: *

Reason for Request: *

Add location

Change of location

License was damaged

License was lost

Other

Explanation: *

Embalmers Add Location

If you have added location(s) please list the name(s) and license number(s) of where you are now employed.

Establishment 1:

Funeral Establishment Name:

License Number:

Establishment 2:

Funeral Establishment Name:

License Number:

Establishment 3:

Funeral Establishment Name:

License Number:

Establishment 4:

Funeral Establishment Name:

License Number:

Embalmers Changed / Removed Location

If you have changed/removed location(s) please list the name(s) and license number(s) of where you no longer work.

Establishment 1:

Funeral Establishment Name:

License Number:

Establishment 2:

Funeral Establishment Name:

License Number:

Establishment 3:

Funeral Establishment Name:

License Number:

Establishment 4:

Funeral Establishment Name:

License Number:

Comment(s):

Preneed Agent

The license number(s) listed in this section must be an active PRENEED SELLER license registered with the board.

License Number: *

Reason for Request: *

Add location

Change of location

License was damaged

License was lost

Other

Explanation: *

Preneed Agent Add Location

If you have added location(s) please list the name(s) and license number(s) of where you are now employed.

Preneed Seller 1:

Preneed Seller Name:

License Number:

Preneed Seller 2:

Preneed Seller Name:

License Number:

Preneed Seller 3:

Preneed Seller Name:

License Number:

Preneed Seller 4:

Preneed Seller Name:

License Number:

Preneed Agent Changed / Removed Location

If you have changed/removed location(s) please list the name(s) and license number(s) of where you no longer work.

Preneed Seller 1:

Preneed Seller Name:

License Number:

Preneed Seller 2:

Preneed Seller Name:

License Number:

Preneed Seller 3:

Preneed Seller Name:

License Number:

Preneed Seller:

Preneed Seller Name:

License Number:

Comment(s):

Preneed Agent Funeral Director

The license number(s) listed in this section must be an active PRENEED SELLER license registered with the board.

License Number: *

Reason for Request: *

Add location

Change of location

License was damaged

License was lost

Other

Explanation: *

Preneed Agent Funeral Director Add Location

If you have added location(s) please list the name(s) and license number(s) of where you are now employed.

Preneed Seller 1:

Preneed Seller Name:

License Number:

Preneed Seller 2:

Preneed Seller Name:

License Number:

Preneed Seller 3:

Preneed Seller Name:

License Number:

Preneed Seller 4:

Preneed Seller Name:

License Number:

Preneed Agent Funeral Director Changed / Removed Location

If you have changed/removed location(s) please list the name(s) and license number(s) of where you no longer work.

Preneed Seller 1:

Preneed Seller Name:

License Number:

Preneed Seller 2:

Preneed Seller Name:

License Number:

Preneed Seller 3:

Preneed Seller Name:

License Number:

Preneed Seller 4:

Preneed Seller Name:

License Number:

Comment(s):

Funeral Establishment

Funeral Establishment: *

License Number: *

Reason for Request: *

License was damaged

License was lost

Other

Explanation: *

Comment(s):

Electronic signature request of: *

Preneed Provider

Preneed Provider Name: *

License Number: *

Reason for Request: *

License was damaged

License was lost

Other

Explanation: *

Comment(s):

Electronic signature request of: *

Preneed Seller

Preneed Seller Name: *

License Number: *

Reason for Request: *

License was damaged

License was lost

Other

Explanation: *

Comment(s):

Electronic signature request of: *

General Inquiries

Board of Embalmers & Funeral Directors

Duplicate License Request

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General Inquiries

Board of Embalmers & Funeral Directors

Duplicate License Request