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)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(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.

Role 1: Permission Group(Required)

Role 1: Facility Name/Location (funeral home name, hospital name, county, etc.)(Required)

Role 2: Permission Group

Role 2: Facility Name/Location (funeral home name, hospital name, county, etc.)

Role 3: Permission Group

Role 3: Facility Name/Location (funeral home name, hospital name, county, etc.)

License Number

Required for Physicians, Embalmers, Funeral Directors, Midwives, Hospice Nurses. For all others, enter none for license type and license number.

License Type – License 1(Required)

License 1 Number(Required)

License Type – License 2

License 2 Number

Signature(Required)

Phone

This field is for validation purposes and should be left unchanged.

Programs & Services

ADH ERAVE User Application Form

Applicant's Data

ERAVE Roles

License Number

Helpful Links

Contact ADH

Your Arkansas.gov

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