Fillable LICENSE OR SOCIAL SERVICE TECHNICIAN REGISTRATION APPLICATION FOR (Michigan)

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LICENSE OR SOCIAL SERVICE TECHNICIAN REGISTRATION APPLICATION FOR (Michigan)

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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
APPLICATION FOR MASTER’S SOCIAL WORKER OR BACHELOR’S SOCIAL WORKER
LICENSE OR SOCIAL SERVICE TECHNICIAN REGISTRATION
Authority: 1978 PA 368
(
This Form Should NOT Be Used For License Renewal)
Applicant’s Legal Name (First, Middle, Last)
U.S. Social Security Number
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number (If Applicable)
Address
City
State
Zip Code
Country
Email Address
List any other name or alias by which you have ever been known, including maiden name, if applicable:
CHECK THE LICENSE/OBTAINED BY METHOD FOR OFFICE USE ONLY
S.S.T. Registration
S.S.T. Reregistration
Limited S.S.T. Registration
Limited S.S.T. Reregistration
L.B.S.W. by Endorsement
L.B.S.W. by Exam
L.B.S.W. Relicensure
Limited L.B.S.W.
Limited L.B.S.W. Relicensure
L.M.S.W. by Endorsement
$43.20 6803-01
$63.20 6803-06
$43.20 6803-03
$63.20 6803-06
$43.20 6802-01
$43.20 6802-01
$63.20 6802-06
$43.20 6802-03
$63.20 6802-06
$43.20 6801-01
License Number
Issue Date
Clinical Macro
L.M.S.W. by Exam $43.20 6801-03
Clinical Macro
Additional Specialty: $16.20 6801-01
Add Clinical (active licensees only)
Add Macro (active licensees only)
L.M.S.W. Relicensure
Limited L.M.S.W.
$63.20 6801-06
$43.20 6801-03
Clinical Macro
Limited L.M.S.W. Relicensure $63.20 6801-06
Your check or money order, drawn from a U.S. financial institution and made
payable to the STATE OF MICHIGAN, must accompany this request. DO NOT
SEND CASH. Fees are non-refundable.
LARA/BPL-SOCIALWORKAPP (Rev. 09/19)
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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LARA/BPL-SOCIALWORKAPP (Rev. 09/19)
2 of 5
Professional Education
Name of School Name of Education Program Graduation Date
License(s) in Other State(s) and/or Country
List each state or country where you have ever held a social work profession license, the license or registration number, the date
issued, how the license was obtained, and whether sanctions have ever been imposed against that license or registration. (Attach
additional sheets as necessary)
If you indicate that there have been sanctions imposed against a license or registration, you must submit documentation that
sanctions are not in force at the time of this application.
State/Country Permanent
License/Registration
Number
Date of
Issuance
How Obtained
(Examination,
Endorsement, or
Compact)
Have You Ever Had
Sanctions Imposed
Against this
License/Registration?
Good Moral Character Questions
If you answer “yes” to either of the next two questions, you must submit a written explanation as to what took place including
date(s) of occurrence(s), court documents, documentation which shows at the current time you have the ability to, and are likely
to, serve the public in a fair, honest, and open manner, that you are rehabilitated, or that the substance of the former offense is
not reasonably related to the occupation or profession for which you are seeking a license.
Answering “yes” to the following question may not automatically prevent you from obtaining a license. In evaluating your good
moral character, the department will consider whether the substance of your former offense is reasonably related to the
profession to which you are seeking a license. Also, please know that you may request a preliminary determination from the
Department concerning whether any court judgments against you would likely result in a denial of a license for failing to meet
the good moral character requirement. More information about requesting a preliminary determination can be found at
www.michigan.gov/healthlicense
.
Have you ever been convicted of a felony?
Yes No
Have you ever been convicted of a misdemeanor punishable by imprisonment for a maximum term
of two years or a misdemeanor involving the illegal delivery, possession, or use of alcohol or
a controlled substance?
Yes No
LARA/BPL-SOCIALWORKAPP (Rev. 09/19)
3 of 5
CERTIFICATION AND SIGNATURE
I understand that it is the policy of this agency to secure a criminal conviction history as part of the pre-licensure screening process. I
authorize this agency to use the information provided in this application to obtain a criminal conviction history file search from the Federal
Bureau of Investigation, Central Records Division of the Michigan Department of State Police, law enforcement, or judicial record-
keeping organization. I consent to the release of information regarding a disciplinary investigation conducted by a similar licensure,
registration, or specialty licensure or specialty certification board of this or any other state, of the United States military, of the federal
government, or of another country.
I certify that the statements in this application are true and complete. I understand that any omitted statement, misrepresentation, or fraud
may be cause for denial of my application, disciplinary action, or may be punishable by law. I further attest that I have a written policy for
protecting, maintaining, and providing access to my medical records in accordance with Section 16213 of the Public Health Code, 1978
PA 368, MCL 333.16213, and for complying with Section 16213 in the event that I sell or close my practice, retire from practice, or
otherwise cease to practice under Article 15 of the Public Health Code, 1978 PA 368, MCL 333.16101 to 333.18838. Further, if I am
applying for relicensure and sign below, I certify that I have completed the required number of continuing education credits.
_
Signature Date
4 of 5
ADDITIONAL DOCUMENTS AND/OR INFORMATION
All Applicants
• Upon review of your application, you will be mailed an Application Confirmation letter containing instructions to complete the Criminal
History Check (except those applicants seeking relicensure/reregistration, if the license/registration expired
within the last three years).
• Transcripts and other forms may be submitted via e-mail at bpldata@michigan.gov by the issuing authorities. In addition, if you
are upgrading a license from the Limited to full Bachelor’s or Master’s level licenses, you are not required to resubmit
transcripts, Certifications of Education, or limited license Supervision Evaluation forms.
• Administrative Rules including Continuing Education Requirements can be found at www.michigan.gov/bpl.
S.S.T. Registration
(must meet one of the following)
• Have each Michigan-licensed L.M.S.W. or L.B.S.W. supervisor and each out-of-state supervisor with an equivalent
license, certificate, or registration in another state submit the completed Supervisor’s Verification of Social Work Experience for Social
Service Technician Form. Each supervisor must verify your social work experience, for a total of 2,000 hours of social work
experience earned over not less than one year.
OR
•
Have the completed Certification of Education for a Social Service Technician Registration form submitted directly to this office by
your school certifying either:
o Completion of an Associate’s degree in Social Work that includes not less than 18 semesters or 27 quarter hours of social
work courses and a field placement or internship of 350 hours under the supervision of a licensed Bachelor’s or Master’s
Social Worker.
OR
o Completion of two years of full time college in an accredited college or university that included some courses relevant
to human services areas.
AND
o Have your supervisor submit the completed Supervisor’s Verification of Social Service Employment form confirming current
employment in human or social services.
S.S.T. Reregistration
• If the registration has been lapsed for MORE than 3 years, submit documentation that an offer of employment has been made in the
practice of social service work at an agency approved by the Board.
Limited S.S.T. Registration
• Have the completed Certification of Education for a Social Service Technician Registration form verifying two years of college
submitted directly to this office by your school.
• Have your supervisor submit the completed Supervisor’s Verification of Social Service Employment for Social Service Technician
form confirming current employment or an offer of employment in human or social services.
L.B.S.W. by Exam or Endorsement
• Have the final official transcripts for a bachelor’s degree from a program accredited by the Council on Social Work Education (CSWE)
forwarded directly to this office from your school. The transcript must include the date the Bachelor’s of Social Work (BSW) degree
was conferred. (You do not need to resubmit transcripts if you currently hold a Limited Bachelor’s Social Worker license.)
• Have each licensed L.M.S.W. supervisor in Michigan or supervisor with an equivalent license, certificate, or registration in another
state complete a Supervisor’s Verification of Social Work Experience for Bachelor’s Social Worker form verifying a total of 4,000
hours of post-degree supervised work experience (accrued over not less than 2 years) submitted directly to this office.
• Must have passed the ASWB Bachelor Examination. If licensure was taken in another state, contact the ASWB at www.aswb.org to
have them submit official copies of your score reports to this office.
Limited L.B.S.W.
• Have the final official transcripts for a bachelor’s degree from a program accredited by the Council on Social Work Education (CSWE)
forwarded directly to this office from your school. The transcript must include the date the Bachelor’s of Social Work (BSW) degree
was conferred.
• Upon issuance of the Limited Bachelor’s Social Worker license, you will be eligible to take the licensing examination required for a
full Bachelor’s Social Worker license. You may contact the Association of Social Work Boards (ASWB) at www.aswb.org
for
information about the exam.
• A limited license shall be issued for 1 year and may be renewed for not more than 6 years, as specified under section 18509(2) of
the code, MCL 333.18509.
LARA/BPL-SOCIALWORKAPP (Rev. 09/19)
5 of 5
L.M.S.W. by Exam or Endorsement
• Have the final official transcripts for a master’s degree from a program accredited by the Council on Social Work Education (CSWE)
forwarded directly to this office from your school. The transcript must include the date the MSW degree was conferred. (You do
not need to resubmit transcripts if you currently hold a Limited Master’s Social Worker license.)
• Have each licensed L.M.S.W. supervisor in Michigan or supervisor with an equivalent license, certificate, or registration in
another state submit a completed Supervisor’s Verification of Social Work Experience for Master’s Social Worker form verifying
a total of 4,000 hours of post-degree supervised work experience directly to this office.
• Must have passed either the ASWB Clinical Examination or the ASWB Advanced Generalist Examination. If exam was taken in
another state, contact the ASWB at www.aswb.org to have them submit official copies of your score report to this office.
Add Clinical or Add Macro (active licensees only)
• Have each licensed L.M.S.W. supervisor i
n Michigan or supervisor with an equivalent license, certificate, or registration in
another state submit a completed Supervisor’s Verification of Social Work Experience for Master’s Social Worker form verifying a
total of an additional 2,000 hours (one year) of post-degree social work experience in the specialty-designated area with at least
50 hours of supervisory review directly to this office.
• Must have passed the ASWB Clinical Examination or the ASWB Advanced Generalist Examination. If exam was taken in another
state, contact the ASWB at www.aswb.org to have them submit official copies of your score report to this office.
L.M.S.W. or L.B.S.W. Relicensure
• Submit documentation of having earned 45 hours of board-approved continuing education within the three-year period immediately
preceding the date of your application with a minimum of five of those hours in ethics and two hours in pain and symptom
management. One half of the required continuing education contact hours must be completed in person using live, synchronous
contact.
• If your license expired MORE THAN THREE YEARS AGO, upon meeting the current licensing requirements and other
requirements, a limited license shall be issued for 1 year. This must be used for the completion of 1,000 hours of practice under the
supervision of a licensed master’s social worker of the same designation.
• If your license expired MORE THAN SEVEN YEARS AGO, in addition to meeting the current licensing requirements and the
requirements above, you must pass the ASWB Clinical Examination or the ASWB Advanced Generalist Examination.
Limited L.M.S.W.
• Have the final official transcripts for a master’s degree from a program accredited by the Council on Social Work Education
(CSWE) forwarded directly to this office from your school. The transcript must include the date the Masters of Social Work (MSW)
degree was conferred.
LARA/BPL-SOCIALWORKAPP (Rev. 09/19)
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Completed 25 February 2021

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