Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 241-0199
www.michigan.gov/bpl
BPLHelp@michigan.gov
CLINICAL AUDIOLOGY WORK EXPERIENCE
Authority: 1978 PA 368
This form must be submitted directly to this office by the supervisor who is verifying your clinical audiology experience.
To be Completed by Applicant:
Applicant’s Legal First Name
Date of Birth (MM/DD/YYYY)
To be Completed by Supervisor:
CERTIFICATION AND SIGNATURE
I
certify the applicant named above practiced audiology under my supervision as defined in MCL 333.16109(2)(b)
beginning on _______________________ and ending on __________________________.
(Month/Day/Year) (Month/Day/Year)
at
(Name of Agency)
located at
(Street Address of Agency)
___________________________
__________________________________________________________________________________________
(City) (State) (Zip Code)
___________________________
________________________________ _____________________________________________
Signature and Title Date
___________________________
________________________________ _____________________________________________
Print or Type Name Type of License/Registration held and State held in
LARA/BPL-AUDIOLOGYCLINEXP (10/2019)
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.
