LARA/BPL-MEDCERTOFAPPTACADINST (Rev. 8/18)
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
CERTIFICATION OF APPOINTMENT TO AN ACADEMIC INSTITUTION
Authority: 1978 PA 368
This form must be submitted directly to this office by the Director of Medical Education office. If this form is submitted by the
applicant, it will not be accepted.
Applicant Information:
Applicant’s Name (First, Middle, Last)
Remainder of Form to be Completed by the Director of Medical Education
Name of Academic Institution
Address of Academic Institution
CERTIFICATION AND SIGNATURE
I certify the applicant named above has been duly appointed to the institution named above in the clinical area of
_____________________________________________________________________________________________________________________
beginning _____________________________ and ending _____________________________,
(Month/Day/Year) (Month/Day/Year)
I further certify that the appointment complies with the requirements of MCL 333.17001 of the Public Health Code, Act 368 of 1978 and Administrative
Rule 338.2435.
_________________________________________________
____________________________________________
Signature of Director of Medical Education Date
_________________________________________________
Print or Type Name of Director of Medical Education
(Seal) If academic institution has no seal, please indicate.
