LARA/BPL-Nursing (Rev. 1/2020)
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.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
BPL-nursecert@michigan.gov
MICHIGAN NURSING SCHOOL CERTIFICATION
Authority: 1978 PA 368
If this form is not completed, a license will not be issued
The Dean, Director, or Registrar of a nursing program in Michigan completes the information below and submits this certification directly to
the Michigan Board of Nursing at BPL-NurseCert@michigan.gov in a PDF. Out-of-state and Canadian Applicants do not use this form.
They MUST have their nursing school submit final official transcripts, showing the degree earned and graduation date via USPS to the
address listed above or use a digital credential service and send to
BPLData@michigan.gov.
Print or Type
Middle Name
Student’s Social Security Number
Student’s Date of Birth (MM/DD/YYYY)
Name of Nursing School where Student Graduated from
Location of Nursing School
Nursing Program Completion Date (this is the date we will use to make the student eligible to take the NCLEX) (Month/Day/Year)
I further certify that the applicant has fulfilled all requirements for:
Licensed Practical Nurse (LPN) Registered Nurse (RN)
Certificate
Associate Degree
Bachelor Degree
Conferred Date: __________________________________________________________.
This is the graduation/commencement date (Month/Day/Year)
___________________________________________ ___________________________________
Signature of Dean, Director, or Registrar Date of Signature
___________________________________________
Type or Print Name of Dean, Director, or Registrar
click to sign
signature
click to edit
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