BPL/LCL-900 (07/15)
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Licensing Division
P.O. Box 30670, Lansing, MI 48909
(517) 373-8068
Information provided on this form may be released to the public in accordance with the Freedom of Information Act, 1976 PA 442, as amended.
Name of Applicant License, Registration or Listing applying for (builder, real estate, etc.)
Street Address City State Zip Code
Type of Application (check one)
Individual Organization (corporation, limited liability
company, partnership, etc.)
If Applicant is an Organization, Name the State in which you are organized.
For the purpose of complying with the laws of the State of Michigan, the undersigned irrevocably appoints the Director of the
Licensing Division, Bureau of Professional Licensing in the Michigan Department of Licensing and Regulatory Affairs or his/her
successor in
office, to be his/her/its attorney to receive service of any lawful process in any non-criminal suit, action, or
proceeding against him/her/it, or his/her/its successor, executor, or administrator, which may arise under the Occupational Code
(being Act number 299 of the Public Acts of 1980, as amended) or any rule or order thereunder after the filing hereof. The
undersigned does hereby consent that any such action, or proceeding against him/her/it may be commenced in any court
of competent jurisdiction and proper venue within the State of Michigan by service of process upon said Director with the same
force and validity as if served upon the undersigned by service personally on its president or other chief officer, if a corporation,
or on one of its partners, if a partnership, or on one of its members, if a limited liability company, or on the individual, if an
Signed in the City of , State of
day of , 20 . Signed
Name of Applicant
If an Organization
State of
County of
Subscribed and sw
orn before me this
day of , 20
Signature of Notary Public
My commission expires
County of State of
If a Corporation, execute and attach a resolution authorizing Consent to Service of Process.
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.