LARA/BPL-CHIROEDUC (Rev. 9/16)
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 CHIROPRACTIC EDUCATION
Authority: 1978 PA 368
This form must be submitted directly to this office by the educational institution you attended. If this form is submitted by the applicant, it
will not be accepted.
Section of Form to be completed by Applicant
Applicant’s Name (First, Middle, Last)
Remainder of Form to be completed by Dean or Registrar of Chiropractic School
Name of Chiropractic School
Address of Chiropractic School
City
State
Zip Code
CERTIFICATION AND SIGNATURE
I certify that the applicant named above attended the chiropractic school named above
from ________________________ to _________________________ and was granted a degree in
(Month/Day/Year) (Month/Day/Year)
___________________________________________.
I also certify that they satisfactorily completed at least 2 years, four semesters or six quarter terms at the chiropractic
school named above.
_____________________________________________________
____________________________________________
Signature of Dean or Registrar Date
_____________________________________________________
Print or Type Name of Dean or Registrar (Seal) If school has no seal, please indicate.
click to sign
signature
click to edit
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