LARA/BPL-CHIROEDUCLMTDSUPV (Rev. 9/16)
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
SUPERVISOR’S CONFIRMATION FORM
FOR CHIROPRACTIC EDUCATIONAL LIMITED LICENSE
Authority: 1978 PA 368
This form must be submitted directly to this office by your supervisor. If this form is submitted by the applicant, it will not be accepted.
Section of Form to be completed by Applicant
Applicant’s Name (First, Middle, Last)
Telephone Number
Email Address
Remainder of Form to be completed by Supervisor
Supervisor’s Name (First, Middle, Last)
10-Digit MI Permanent ID/License Number
Expiration Date
Current Business Address
Current Position
CERTIFICATION AND SIGNATURE
I certify that I am a licensed chiropractor in the State of Michigan and will supervise the above named individual during the
practice portion of his or her chiropractic education. As a direct supervisor, I will conform to all existing laws and rules
governing such supervision.
Start date for Educational Limited license: ________________________________
________________________________________________________
____________________________________________
Signature of Supervisor Date
________________________________________________________
Print or Type Name of Supervisor
click to sign
signature
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