LARA/BPL-MEDCERTTRAIN (Rev. 4/19)
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
CLINICAL ACADEMIC LIMITED LICENSE HOLDERS SEEKING FULL LICENSURE
CERTIFICATION 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:
Date of Birth (MM/DD/YYYY)
Email Address
Remainder of Form to be Completed by Director of Medical Education:
Address of Institution
CERTIFICATION AND SIGNATURE
I certify the applicant named above has successfully completed not less than 3 years of postgraduate clinical training in the institution
named above in the clinical area of
___________________________________________________________________________________________________________________.
(Program Name)
from
_____________________________ to _____________________________.
I further certify that the institution named above is affiliated with a medical school that is listed in a directory of medical schools published
by the World Health Organization (WHO).
_____
____________________________________________
____________________________________________
Signature of Director of Medical Education Date
_________________________________________________
Print or Type Name of Director of Medical Education (Seal) If hospital has no seal, please indicate.
