Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0560
www.michigan.gov/bpl
BPLHelp
CERTIFICATION OF PRACTICE IN AN ACADEMIC INSTITUTION
Authority: 1978 PA 368
This form must be submitted directly to this office by the Director of Medical Education office where you practiced under a clinical
academic limited license. A separate form will need to be submitted by each academic institution in which the applicant practiced under.
If this form is submitted by the applicant, it will not be accepted.
Applicant Information:
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number
Remainder of Form to be Completed by Director of Medical Education:
Name of Academic Institution
Address of Academic Institution
CERTIFICATION AND SIGNATURE
I certify the applicant named above has functioned not less than 800 hours per year in the observation and treatment of patients for the
above academic institution. In doing so, the applicant practiced medicine safely and competently
beginning
_________________________________ and ending _________________________________,
Month/Day/Year) (Month/Day/Year)
I further certify that the above named academic institute meets the requirements of MCL 333.17001 of the Public Health Code, Act 368
of 1978.
Signature of Director of Medical Education Date
(SEAL)
If hospital has no seal, please indicate.
Print or Type Name of Director of Medical Education
LARA/BPL-MEDCERTCLINPRAC (Rev. 7/18)
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.
