Fillable AND OCCUPATIONAL THERAPY ASSISTANT LICENSURE AND RELICENSURE APPLICATION (Michigan)

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AND OCCUPATIONAL THERAPY ASSISTANT LICENSURE AND RELICENSURE APPLICATION (Michigan)

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The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin,
color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you
may make your needs known to this agency.
LARA/BPL-OTNew/Relic (Rev. Date 9/19)
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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
APPLICATION FOR OCCUPATIONAL THERAPIST
AND OCCUPATIONAL THERAPY ASSISTANT LICENSURE AND RELICENSURE
Authority: 1978 PA 368
**THIS FORM SHOULD NOT BE USED TO RENEW YOUR LICENSE **
Print or Type Clearly Legal Name
Applicant’s First Name
Middle Name
Last Name
U.S. Social Security Number
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number (If Applicable)
Address
City
State
Zip Code
Country
Email Address
List any other name or alias by which you have ever been known, including maiden name, if applicable:
____________________________________________________________________________________
CHECK THE LICENSE/OBTAINED BY METHOD
FOR OFFICE USE ONLY
Occupational Therapist – By Endorsement $102.70 5201-09
Occupational Therapist – By Exam
$102.70 5201-01
Occupational Therapist – Relicensure $122.70 5201-06
Occupational Therapist Asst. – By Endorsement $102.70 5202-09
Occupational Therapist Asst. – By Exam $102.70 5202-03
Occupational Therapist Asst. – Relicensure $122.70 5202-06
Your check or money order, drawn from a U.S. financial institution and
made payable to the STATE OF MICHIGAN,
must accompany this
request. DO NOT SEND CASH. Fees are non-refundable.
License Number
Issue Date
LARA/BPL-OTNew/Relic (Rev. Date 9/19)
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Professional Education
(Attach additional sheets if necessary)
Name of School
Name of Degree Granted
License(s) in Other State(s) and/or Country
List each state or country where you have ever held an occupational therapy license, the license or registration number,
the date issued, how the license was obtained, and whether sanctions have ever been imposed against that license or
registration. (Attach additional sheets if necessary)
If you indicate there have been sanctions imposed against a license or registration, you must submit documentation that
sanctions are not in force at the time of this application.
State/Country
Permanent
License/Registration
Number
Date of
Issuance
How Obtained
(Examination/
Endorsement)
Have You Ever Had
Sanctions Imposed
Against this
License/Registration?
Good Moral Character Questions
If you answer “yes” to either of the next two questions, you must submit a written explanation as to what took place
including date(s) of occurrence(s), court documents, documentation which shows at the current time you have the ability
to, and are likely to, serve the public in a fair, honest, and open manner, that you are rehabilitated, or that the substance
of the former offense is not reasonably related to the occupation or profession for which you are seeking a license.
Answering “yes” to the following question may not automatically prevent you from obtaining a license. In evaluating your
good moral character, the department will consider whether the substance of your former offense is reasonably related
to the profession to which you are seeking a license. Also, please know that you may request a preliminary determination
from the Department concerning whether any court judgments against you would likely result in a denial of a license for
failing to meet the good moral character requirement. More information about requesting a preliminary determination
can be found at www.michigan.gov/healthlicense
.
Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a misdemeanor punishable by imprisonment for a maximum Yes No
term of two years or a misdemeanor involving the illegal delivery, possession, or use of alcohol
or a controlled substance?
LARA/BPL-OTNew/Relic (Rev. Date 9/19)
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CERTIFICATION AND SIGNATURE
I understand that it is the policy of this agency to secure a criminal conviction history as part of the pre-licensure screening process. I
authorize this agency to use the information provided in this application to obtain a criminal conviction history file search from the
Federal Bureau of Investigation, Central Records Division of the Michigan Department of State Police, law enforcement, or judicial
record-keeping organization. I consent to the release of information regarding a disciplinary investigation conducted by a similar
licensure, registration, or specialty licensure or specialty certification board of this or any other state, of the United States military, of
the federal government, or of another country.
I certify that the statements in this application are true and complete. I understand that any omitted statement, misrepresentation, or
fraud may be cause for denial of my application, disciplinary action, or may be punishable by law. I further attest that I have a written
policy for protecting, maintaining, and providing access to my medical records in accordance with Section 16213 of the Public Health
Code, 1978 PA 368, MCL 333.16213, and for complying with Section 16213 in the event that I sell or close my practice, retire from
practice, or otherwise cease to practice under Article 15 of the Public Health Code, 1978 PA 368, MCL 333.16101 to 333.18838.
_______________________________________________ ___________________________________
Signature of Applicant Date
_______________________________________________
Printed Name of Applicant
click to sign
signature
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LARA/BPL-OTNew/Relic (Rev. Date 9/19)
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Required Additional Documents:
All Applicants
• Upon review of your application, you will be mailed an Application Confirmation letter containing instructions to
complete the Criminal Background Check (except those applicants seeking relicensure, if the license expired
within the last three years).
• An applicant whose occupational therapist or occupational therapy assistant educational program was taught in a
language other than English shall submit a certified score on the Test of English as a Foreign Language – Internet
Based Test (TOEFL-IBT).
• All applicants for licensure and relicensure must take and pass the jurisprudence examination before licensure can
be issued (except those applicants seeking relicensure, if the license expired within the last three years).
The passing score on the exam is 75%. The jurisprudence examination covers material that can be found in the
Administrative Rules of the Michigan Board of Occupational Therapy and the Michigan Public Health Code Article
1, parts 11 and 12 and Article 15, parts 161 and 183. Licensure candidates must take the jurisprudence examination
through PSI. You may contact PSI to schedule your exam by visiting www.psiexams.com or by calling PSI at 800-
733-9267.
• Human Trafficking requirement – Administrative Rule R 338.1215: Proof of completion of training to identify victims
of human trafficking. This is a one-time training that is separate from continuing education (CE). Licensees renewing
for 2018 must complete training by renewal in 2020; renewals for 2019 by 2021, and renewals for 2020 by 2022.
Beginning October 19, 2022, completion of the training is a requirement for initial licensure.
NOTE – NEW CONTINUING EDUCATION REQUIREMENT FOR RENEWAL AND RELICENSURE:
Administrative Rule R 338.1251: An applicant for license renewal who has been licensed for the 2-
year period
immediately preceding the expiration date of the license shall accumulate not less than 20 continuing education contact
hours that are approved by the board pursuant to R 338.1252 during the 2 years preceding an application for renewal. A
minimum of 10 hours must be completed in-person with live, synchronous contact and a minimum of 1 hour in pain and
symptom management. Licensees renewing in 2019 must complete continuing education by renewal in 2021; renewals
for 2020 by renewal in 2022, etc.
Applicants whose license have lapsed for 3 years or more and are filing for relicensure effective June 2021 and after are
subject to R 338.1227 and R 338.1236 and are required to complete continuing education.
Occupational Therapist/Occupational Therapy Assistant License by Endorsement
Applicants for licensure by endorsement who have been licensed in another state and have practiced
occupational therapy for 5 years or more immediately preceding the date of application must submit the
following:
• Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as an occupational therapist/therapist
assistant. Verification includes, but is not limited to, showing proof of any disciplinary action taken or pending
disciplinary action imposed.
• Certification of your NBCOT passing examination scores submitted directly to this office from the examination
agency. ONLY an Occupational Therapist may submit either NBCOT scores or certification of passing the
predecessor examination that was administered by the AOTA. Contact the National Board for Certification in
Occupational Therapy (NBCOT) to have the results sent directly to this office if you did not request that your scores
be sent to Michigan when you took the exam. Contact the NBCOT at (301) 990-7979 or on their website
www.nbcot.org
.
• Certification of your passing the jurisprudence examination. Must have passed exam within 3 years preceding the
application for endorsement.
LARA/BPL-OTNew/Relic (Rev. Date 9/19)
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Occupational Therapist/Occupational Therapy Assistant License by Endorsement Continued
Applicants for licensure by endorsement who have been licensed in another state and have practiced
occupational therapy for less than 5 years immediately preceding the date of application must submit the
following:
• Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as an occupational therapist/therapist
assistant. Verification includes, but is not limited to, showing proof of any disciplinary action taken or pending
disciplinary action imposed.
• Certification of your NBCOT passing examination scores submitted directly to this office from the examination
agency. ONLY an Occupational Therapist may submit either NBCOT scores or certification of passing the
predecessor examination that was administered by the AOTA. Contact the National Board for Certification in
Occupational Therapy (NBCOT) to have the results sent directly to this office if you did not request that your scores
be sent to Michigan when you took the exam. Contact the NBCOT at (301) 990-7979 or on their website
www.nbcot.org
.
• Official transcripts submitted directly to this office from the approved occupational therapy educational program from
which you graduated. Transcripts must include the date your occupational therapy degree was conferred.
• Certification of your passing the jurisprudence examination. Must have passed exam within 3 years preceding the
application for endorsement.
Occupational Therapist/Occupational Therapy Assistant License by Exam
• Official transcripts submitted directly to this office from the approved occupational therapy educational program from
which you graduated. Transcripts must include the date your occupational therapy degree was conferred. For
Occupational Therapist, must have graduated from an occupational therapy educational program that is accredited
by the Accreditation Council for Occupational Therapy Education (ACOTE) or approved by the World Federation of
Occupational Therapists (WFOT). For Occupational Therapy Assistant, must have graduated from an Occupational
Therapy Assistant program that is accredited by the ACOTE.
• Certification of your NBCOT passing examination scores submitted directly to this office from the examination
agency. Examination must have been taken and passed within 3 years preceding the date of application for
licensure. Contact the National Board for Certification in Occupational Therapy (NBCOT) to have the results sent
directly to this office if you did not request that your scores be sent to Michigan when you took the exam. Contact
the NBCOT at (301) 990-7979 or on their website www.nbcot.org
.
• Certification of your passing the jurisprudence examination. Must have passed exam within 3 years preceding the
application for licensure.
Occupational Therapist/Occupational Therapy Assistant Relicensure
Applicants for an occupational therapist/occupational therapy assistant license by relicensure who’s license
has been lapsed for 3 years or LESS at the time of application must submit the following:
• Establish good moral character.
• Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as an occupational therapist/therapist
assistant. Verification includes, but is not limited to, showing proof of any disciplinary action taken or pending
disciplinary action imposed.
LARA/BPL-OTNew/Relic (Rev. Date 9/19)
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Requirements for Relicensure Continued
Applicants for an occupational therapist/occupational therapy assistant license by relicensure who’s license
has been lapsed for MORE than 3 years at the time of application must submit the following:
• Establish good moral character.
• Within 3 years preceding the application date for relicensure, you must take and pass the jurisprudence examination
before licensure can be issued. The passing score on the exam is 75%. The jurisprudence examination covers
material that can be found in the Administrative Rules of the Michigan Board of Occupational Therapy and the
Michigan Public Health Code Article 1, parts 11 and 12 and Article 15, parts 161 and 183. Licensure candidates
must take the jurisprudence examination through PSI. You may contact PSI to schedule your exam by visiting
www.psiexams.com or by calling PSI at 800-733-9267.
• Submit fingerprints and undergo a Criminal Background Check. Fingerprints must be taken using the Customer ID
number. Instructions will be provided with the Application Confirmation letter that will be sent when your application
and fee are processed. DO NOT have your fingerprints taken prior to receiving this information.
• Applicants whose license have lapsed for 3 years or more and are filing for relicense effective June 2021 and after
are subject to R 338.1227 and 338.1236 and are required to complete continuing education. Submit proof of
completing no less than 20 continuing education hours that are approved by the board pursuant to R 338.1252. A
minimum of 10 hours must be completed in-person with live, synchronous contact and a minimum of 1 hours in pain
and symptom management.
• Meet either of the following requirements:
a. Certification of your NBCOT passing examination scores submitted directly to this office from the examination
agency. Examination must have been taken and passed within 3 years preceding the date of application for
relicensure. Contact the National Board for Certification in Occupational Therapy (NBCOT) to have the results
sent directly to this office if you did not request that your scores be sent to Michigan when you took the exam.
Contact the NBCOT at (301) 990-7979 or on their website www.nbcot.org
AND meet the required supervised
practice experience as outlined below.
b. Verification that you have been an occupational therapist/occupational therapy assistant in another state
during the 3-year period immediately preceding the application for relicensure. Verification/certification of
license to be submitted directly to this office by the licensing agency of any state or territory of the United
States in which you hold a current license or ever held a license as an occupational therapist/therapist
assistant. Verification includes, but is not limited to, showing proof of any disciplinary action taken or pending
disciplinary action imposed.
Applicants who meet requirement (a) above shall complete the following requirements:
• Supervised practice experience that meets the requirements of R 338.1228 for occupational therapist and
R338.1237 for occupational therapy assistant along with the duration of the experience shall be as follows:
a. If license has been lapsed for at least 3 years but less than 7 years – applicant shall complete not less than
200 hours of supervised practice experience.
b. If license has been lapsed for 7 years to 15 years – applicant shall complete not less than 400 hours of
supervised practice experience.
c. If license has been lapsed for more than 15 years – applicant shall complete not less than 600 hours of
supervised practice experience.
• Verification/certification of license to be submitted directly to this office by the licensing agency of any state or territory
of the United States in which you hold a current license or ever held a license as an occupational therapist/therapist
assistant. Verification includes, but is not limited to, showing proof of any disciplinary action taken or pending
disciplinary action imposed.
NOTE: If an applicant for relicensure needs to complete the supervised practice experience, the applicant may
petition the Department to be granted a 1-year limited license for the sole purpose of completing the required
work experience. You must submit your request in writing at the time you apply for relicensure.
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AND OCCUPATIONAL THERAPY ASSISTANT LICENSURE AND RELICENSURE APPLICATION (Michigan)

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Completed 9 February 2021

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