LARA/BPL-DENTSPECIALCERT (Rev. 09/16)
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 SPECIALTY PROGRAM
Authority: 1978 PA 368
This form must be submitted directly to this office by the hospital administrator where the specialty program was completed. If this form is
submitted by the applicant, it will not be accepted.
Applicant’s Name (First, Middle, Last)
Date of Birth
Name of Hospital
Remainder of Form to be Completed by Hospital Administrator:
CERTIFICATION AND SIGNATURE
I certify the above named applicant has satisfactorily completed dental post graduate training from an approved graduate
program of dentistry for the following specialty:
___________________________________________________________
____________________________________________________
____________________________________________
Signature of Hospital Administrator Date
____________________________________________________
Print or Type Name and Title of Hospital Administrator (Seal)
click to sign
signature
click to edit
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