LARA/BPL-DPACERT (Rev. 10/18)
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.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
VERIFICATION OF DIAGNOSTIC PHARMACEUTICAL AGENTS (DPA) TRAINING
Authority: 1978 PA 368
Section of Form to be Completed by Applicant:
Applicant’s Name (First, Middle, Last)
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number
Email Address
List any other name or alias by which you have ever been known, including maiden name, if applicable:
Remainder of Form to be Completed by School of Optometry:
From: ____________________________________ To: _____________________________________
CERTIFICATION AND SIGNATURE
I hereby certify that the applicant named above has completed a minimum of 60 classroom hours in general and clinical pharmacology as
it relates to the practice of optometry with particular emphasis on the use of diagnostic pharmaceutical agents for examination purposes.
Not less than 30 of the 60 classroom hours were allocated to ocular pharmacology and emphasized the systemic effects of, and reactions
to, topical ocular diagnostic pharmaceutical agents, including the emergency management and referral of any adverse reactions that may
occur.
The doctor named above has also successfully completed an examination on general and ocular pharmacology as it relates to the practice
of optometry, with particular emphasis on the use of topical ocular diagnostic pharmaceutical agents, including emergency management
and referral of any adverse reactions that may occur.
____________________________________________ ____________________________________________
Signature of Dean or Registrar Title
____________________________________________ ____________________________________________
Print or Type Name Date
(SCHOOL SEAL)
