LARA/BPL-MED/DOCERTTRAIN (Rev. 2/2020)
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.
CERTIFICATION OF COMPLETION OF POSTGRADUATE TRAINING
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.
Licensee Information:
Licensee’s First Name
Middle Name
Date of Birth (MM/DD/YYYY)
Remainder of Form to be Completed by Director of Medical Education:
Name of Hospital or Institution
Address of Hospital or Institution
CERTIFICATION AND SIGNATURE
I certify the applicant named above has successfully completed postgraduate training offered by the hospital or institution named
above in the clinical area of
___________________________________________________________________________________________________________________.
(Program Name)
from
_____________________________ to _____________________________.
PLEASE CHECK APPROPRIATE BOX BELOW:
MD ONLY - I further certify that this is an active program accredited by the ACGME, the College of Family Physicians of Canada,
the Royal College of Physicians and Surgeons of Canada or the Canadian Medical Association’s Conjoint Accreditation Services.
DO ONLY - I further certify that this postgraduate training is accredited by the American Osteopathic Association Council or the
Accreditation Council of Graduate Medical Education.
_________________________________________________
____________________________________________
Signature of Director of Medical Education Date
_________________________________________________
Print or Type Name of Director of Medical Education (Seal) If hospital has no seal, please indicate.
NOTE: MD ONLY- Certification of Completion of Postgraduate Training may be submitted to the department no more than 15 days
prior to the scheduled date of completion. If signed and submitted sooner, it will not be accepted.
DO ONLY- Certification of Completion of Postgraduate Training may be submitted to the department no more than 30 days prior to the
scheduled date of completion. If signed and submitted sooner, it will not be accepted.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
