LARA/BPL-MEDCERTOFAPPTTRAINHOSP (Rev. 10/2020)
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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
BPLData@michigan.gov
CERTIFICATION OF APPOINTMENT TO A MICHIGAN TRAINING HOSPITAL
FOR A MEDICAL DOCTOR LICENSE
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.
Applicant Information:
Applicant’s First Name
Middle Name
Address
City
State
Zip Code
Date of Birth (MM/DD/YYYY)
Remainder of Form to be Completed by Director of Medical Education
Name of Training Hospital
ACGME Program Number (If applicable)
CERTIFICATION AND SIGNATURE
I certify the applicant named above has been duly appointed to the training program in the clinical area of
____________________________________________________________________________________
(Program Name)
beginning _____________________________ and ending _____________________________,
(Month/Day/Year) (Month/Day/Year)
Per R338.2421(2), is this an active postgraduate training program that is accredited by the Accreditation Council for Graduate Medical
Education (ACGME)?
Yes No
_________________________________________________
____________________________________________
Signature of Director of Medical Education Date
_________________________________________________
Print or Type Name of Director of Medical Education (Seal) If hospital has no seal, please indicate.
