LARA/BPL-TEMPMILSPOUSE (Rev. 5/19
2 of 2
Required Documents for All Applicants:
Please be advised that the initial Military Spouse Temporary license is valid for only a 6-month period. The license can be
renewed for 1 additional 6-month period if the board determines that you continue to meet the requirements of MCL
333.16181(5) of the Michigan Public Health Code and needs additional time to fulfill the requirements for initial licensure.
If you want to renew the temporary license, submit the renewal form prior to the end of the 6 month expiration of your initial
temporary license.
• Upon review of your application, you will be mailed an Application Confirmation letter containing instructions to complete
the Criminal Background Check.
• Proof you hold a current license in good standing, or a current registration in good standing, in that health profession
for which you are applying, issued by an equivalent licensing department, board, or authority, in another state of the
United States, the District of Columbia, Puerto Rico, the United States Virgin Islands, another territory or protectorate
of the United States, or a foreign country.
• Proof that you are married to a member of the armed forces of the United States.
• Proof that your spouse is on active duty.
• Proof that your spouse is assigned to a duty station in Michigan and that you are also assigned to a duty station in
Michigan under your spouse’s permanent change of station orders.
CERTIFICATION AND SIGNATURE
I understand that it is required by law that this agency secure a criminal history check as part of the pre-licensure screening
process. I authorize this agency to use the information provided in this application to obtain a criminal history file search
from the Federal Bureau of Investigations, 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.
_______________________________________________ ___________________________________
Signature Date
YES NO
YES
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 profes
sion 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 .
NO
Have you ever been c
onvicted of a felony?
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?
