LARA/BPL-TEMPMILSPOUSEREN (Rev. 10/18)
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Required Documents for Renewal for All Applicants:
Military Spouse temporary licenses can be renewed for 1 additional 6 month term if the board determines the temporary
licensee continues 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.
• 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.
GOOD MORAL CHARACTER QUESTIONS
1. Have you been convicted of a felony you have not previously reported to the Department?
2. H
ave you been convicted of a misdemeanor punishable by imprisonment for a maximum of
2 years or a misdemeanor conviction involving the illegal delivery, possession, or use of
alcohol or a controlled substance you have not previously reported to the Department?
3. Have any sanctions been imposed against you by a similar licensure, registration,
certification or disciplinary board of another state or country you have not previously report
to the Department?
4. I hav
e 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, MC
L
333.16213 and for complying with Section 16213(4) 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 MCL 333.18838.
CERTIFICATION AND SIGNATURE
I understand by signing this renewal application, I certify all information to be true and correct and 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.
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Signature Date
