Fillable MI Bureau of Professional Licensing PO Box 30670 (Michigan)

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MI Bureau of Professional Licensing PO Box 30670 (Michigan)

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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-7500
www.michigan.gov/bpl
BPL-BoardSupport@michigan.gov
VOLUNTEER DENT AL SPONSOR APPLICATION
Authority: 1978 PA 368
(
LARA/BPL-VOLDENTALCE (Rev. 10/2020)
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.
Sponsor Name
Sponsor Street Address
City
State
MI
Zip Code
Contact Person
Phone Number
Previous Michigan Approval Number and Expiration Date: (if applicable)
What type of entity, program, or event does the sponsor represent?
Public Entity Educational Institution Nursing Home Non-profit Organization
Does the sponsor provide dental services to indigent or dentally underserved populations? Yes No
List the names and titles of all responsible parties below.
Name
Title
Name
Title
Name
Title
Has any member of this organization been the subject of any past or present disciplinary action? Yes No
If yes, please explain:
How long has this organization provided dental care to underserved populations?
All certificates should show the following for use in Michigan for continuing education credit:
• The name of the sponsoring organization
• The approval number assigned to your organization
• The name of the licensee
• The dates and times of volunteer services provided
• The number of continuing education credits earned
• A signature of the individual responsible for attendance
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Required Additional Documents
•
The Volunteer Dental Dates form, providing the location, dates and times of services provided. If additional dates are
to be added after approval of the sponsor application, the information must be submitted to our office.
•
Sample attendance documents.
•
Sample completion certificate.
•
This application may be submitted to this office by emailing the form and required documents to
BPL-BoardSupport@michigan.gov
CERTIFICATION AND SIGNATURE
I hereby certify that the statements made in this application are true, complete, and correct, and the
materials submitted
accurately reflect the presentation and administration of this continuing education program. I further certify that if volunteer
sponsor approval is granted by the Board of Dentistry, accurate, permanent individual records will be maint
ained. Written
evidence of attendance containing the approval number assigned to the sponsor shall be provided to each participating
volunteer.
If not signed and dated, your application will not be complete.
_ _ _ _
Signature Title
_ _ _ _
Print or Type Name Date
LARA/BPL-VOLDENTALCE (Rev. 10/2020)
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MI Bureau of Professional Licensing PO Box 30670 (Michigan)

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Completed 9 February 2021

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