ERAVE User Application Form

ADH ERAVE User Application Form

Completed the form and sign the user agreement. Once completed, select SUBMIT.

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Applicant's Data

Name(Required)
Business Address(Required)

ERAVE Roles

Permisson Groups: Funeral Directors, Funeral Director Assistant, Coroner, Deputy Coroner, Physician, Physician Clinic Staff, Medical Examiner, Medical Examiner Office Staff, Medical Examiner Assistant, Hospital Death Clerk, Birthing Clerk, Midwife, Hospice RN, and Local Health Unit. List each group/location combination separately.

License Number

Required for Physicians, Embalmers, Funeral Directors, Midwives, Hospice Nurses. For all others, enter none for license type and license number.
This field is for validation purposes and should be left unchanged.

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