LARA/BPL-MEDCERTEDUS (Rev. 8/18)
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
CERTIFICATION OF MEDICAL EDUCATION
FOR GRADUATES OF MEDICAL SCHOOLS LOCATED IN THE UNITED STATES,
ITS TERRITORIES, THE DISTRICT OF COLUMBIA, OR THE DOMINION OF CANADA
Authority: 1978 PA 368
This form must be submitted directly to this office by the dean or registrar of medical school. If this form is submitted by the applicant,
it will not be accepted.
Applicant Information:
Date of Birth (MM/DD/YYYY)
Telephone Number
Email Address
Name of Medical School
Remainder of Form to be Completed by the Dean or Registrar of the Medical School
Address of Medical School
CERTIFICATION AND SIGNATURE
I certify the applicant named above was / will be granted the degree of ________________________________________
on _____________________________.
(Month/Day/Year)
_______
__________________________________________ ________________________________________
Signature of Dean or Registrar Date
_______
__________________________________________ (Seal)
Print or Type Name of Dean or Registrar
NOTE: Form will not be accepted if submitted more than 3 months prior to graduation and/or the date of application for licensure.
