Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-9288
www.michigan.gov/bpl
BPLHelp@michigan.gov
CONSENT TO SERVICE OF PROCESS
(FOR NONRESIDENTS ONLY)
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 (First, Middle, Last) 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.
KNOW ALL PERSONS BY THESE PRESENTS:
Fo
r 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
individual.
Signed in the City of , State of
this day
of
, 20 . Signed
Name of Applicant
By
If an Organization
Title
State of
County of
Subscribed and sworn 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/BPL-CSP (Rev. 06/16)
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.
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