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Michigan Department of Licensing and Regulatory Affairs Bureau (Michigan)

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Board Use Only
LARA/RCD-802 (01/19)
Please PRINT Clearly
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Enforcement Division
P.O. Box 30670
Lansing, MI 48909
(517) 241-0199
www.michigan.gov/healthlicense
First Name
Middle Name
Last Name
Street Address
City
State
Zip Code
Telephone Number w/Area Code
Date of Birth (MM/DD/YY)
Michigan Professional License Number
SIGNATURE
Date
E-mail Address
RECLASSIFICATION OF DISCIPLINARY LIMITED LICENSE
Authority: Michigan Public Heal
th Code, Public Act 368 of 1978
, as amended
U.S. Social Security Number
Please read carefully:
1. Submit this application, along with the required supporting documents, to the address shown above.
2. All supporting affidavits* must be notarized.
3. All supporting documents must be attached to this application.
4. Submission by separate mailing of the supporting documents is not acceptable and will cause rejection of your application.
5. The proper fee, as listed above, must accompany this application or it will be rejected.
6. Instructions for the criminal background check** will be provided to you upon the department’s receipt of this form.
* A minimum of two (2) supporting affidavits are required that demonstrates:
A. you will practice safely and competently within the area of practice, and
B. it is in the public interest that your license be reclassified.
** Section 333.16245(8): An individual who seeks reclassification of a limited license pursuant to this section shall have a criminal
history check conducted in accordance with section 16174.
Check the profession for which you are requesting reclassification. Submit the appropriate fee indicated by the profession. Make your
check or money order payable to the STATE OF MICHIGAN. Do not send cash. Fees are earned upon receipt and can only be refunded
under rules promulgated by the Department.
Please Note: Behavior Analyst, Dentistry, Medicine, Midwifery, Nursing, Optometry, Osteopathic Medicine,
Pharmacy, Physicians Assistants, Podiatry and Veterinary Medicine applications must be submitted online
at: www.michigan.gov/miplus
Facility Name (if applicable)
ACUPUNCTURIST - $81.10 (54-01-50)
ATHLETIC TRAINER - $81.10 (26-01-50)
AUDIOLOGIST - $129.80 (16-01-50)
D.C. - $27.00 (23-01-50)
M.F.T. - $32.40 (41-01-50)
MASSAGE THERAPY - $21.60 (75-01-50)
N.H.A. - $16.20 (48-01-50)
O.T. - $21.60 (52-01-50)
O.T.A. - $21.60 (52-02-50)
PHARM-CS - $10.80 (37-57-50)
P.T. - $21.60 (55-01-50)
P.T.A. - $21.60 (55-01-50)
PSYCHOLOGIST - $59.45 (63-01-50)
L.L.P. - $59.45 (63-01-50)
L.P.C. - $59.45 (64-01-50)
L.L.P.C. - $59.45 (64-01-50)
R.T. - $21.60 (44-01-50)
SANITARIAN - $27.00 (67-01-50)
SPEECH LANG - $21.60 (71-01-50)
S.S.T. - $16.20 (68-03-50)
L.B.S.W. - $16.20 (68-02-50)
L.M.S.W. - $16.20 (68-01-50)
AFFIDAVITS INFORMATION SHEET
Please read carefully
The statute governing the powers of a notary public reads in pertinent part:
“Notaries public shall have authority to take the proof and acknowledgments of deed; to administer oaths and
take affidavits in any matter or cause pending, or to be commenced….”
The law of the State of Michigan requires that signatures to certain legal instruments (in this case affidavits) be
acknowledged before a person authorized by law to take acknowledgments, such as a notary public. This is
required so that such instruments can be recorded. An example of how an acknowledgment is taken would be as
follows:
John Doe appe
ars before a notary public with the unsigned instrument and, in the presence of the notary
public, signs the instrument and then acknowledges to the notary public that the signature on the
instrument is his, that he is the person indicated in the instrument and that he signed the instrument
voluntarily and without duress. The notary public then certifies on the instrument itself that it was
acknowledged in his/her presence. In the certification, the notary public is stating in his/her official
capacity that the person so signing was the person he claimed to be. Obviously, when a notary public is
not familiar with the person whose acknowledgment he/she is certifying, the notary public should request
that some type of identification be shown.
The notary's signature and stamp alone are not sufficient for the affidavit to be
considered notarized by the Department, it must also include the date of signature.
The wording and format of the certification required on each affidavit is shown in the
example below:
Subscribed and sworn to before me this ___1
st
___ day of ________May________, 20_17_.
___(Notary signature here)_____Jane P. Doe______________________________________
Notary Public __(Notary name printed here)_Jane P. Doe____ __(County Name)__County
My Commission expires: _____(12/31/2020)_____
Additional Facts:
1. A notary publ
ic cannot certify the acknowledgment to an instrument to which he/she, himself/herself, has an
interest. A notary public may take the acknowledgement of a relative, including a spouse; however, in order
to avoid questions of conflict of interest, an independent notary public should be used.
2. An affidavit
is a written or printed declaration or statement of facts. It must be made voluntarily and
confirmed by the oath or affirmation of the party making it, made before a notary public. The notary public
must administer the oath or affirmation prior to the taking of the affidavit.
Affidavits are written statements by individuals, made on oath, before a notary public or other person
authorized to administer oaths. At minimum, an affidavit must contain the following: Signature of
the party making the sworn statement and the date of the signature; signature of notary public and
date notarized; the typed, printed or stamped name of notary; and the state, county and expiration
date of the notary’s commission.
Revised 03/20
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Courtesy of www.michigan.gov/orr
R 792.10712 Limited license; reclassification; standards and procedures.
Rule 712.
(1) The limitations on a license shall continue until the expiration of the period of limitation set forth in the order or until
the license is reclassified pursuant to this rule, whichever is later. The period of limitation set forth in the order is
a minimum period.
(2) A petition for reclassification of a license that has been limited shall be made in accordance with this
rule.
(3) If a license is limited for 1 year or less, it is presumed that the petitioner meets the requirements of
section 7316 or 16249 of the code, MCL 333.7316 or MCL 333.16249, unless 1 of the following provisions applies:
(a) The order imposing the limitations provides otherwise.
(b) Another complaint has been filed and is pending at the end of the period of limitation.
(c) A subsequent disciplinary order has been entered.
(d) A response in opposition to reclassification has been filed by a complaining party alleging that the
petitioner has failed to fulfill a term of the order imposing the limitations.
(4) If a license is limited for an unspecified period of time or for more than 1 year, or if the petitioner is not entitled to a
presumption pursuant to subrule (3) of this rule, then the license shall not be reclassified until the disciplinary
subcommittee finds that the petitioner meets the requirements of section 7316 or 16249 of the code, MCL 333.7316 or
MCL 333.16249.
(5) A petition, with supporting affidavits, shall not be filed for at least 1 year after the effective date of the
order imposing the limitations, unless otherwise provided in the order.
(6) Within 30 days after the petition is filed, a complaining party may file a response to the petition.
If the response opposes the reclassification, a hearing shall be scheduled. If the petitioner fails to appear
at the scheduled hearing, either in person or by counsel, the petitioner shall be deemed in default. If a response
is not filed or if the response does not oppose reclassification, the disciplinary subcommittee shall
review the petition with supporting affidavits and shall determine whether the requirements of section 7316 or
16249 of the code have been met. If it is found that the requirements have not been met, the petitioner shall
be notified and, within 30 days after service of the notice, may request a hearing. The petition for
reclassification shall be deemed denied if the petitioner does not file a timely request for a hearing.
(7) After a hearing has been completed, the disciplinary subcommittee shall determine
whether the petitioner has satisfied section 7316 or 16249 of the code. The disciplinary subcommittee may
deny the petition or grant the petition subject to such terms and conditions as it may deem appropriate.
(8) A subsequent petition for reclassification shall not be filed with the department for at least 1 year after the
effective date of the order denying reclassification, unless otherwise ordered by the disciplinary subcommittee.
History: 2015 AACS.
R 792.10707 Burden of proof.
Rule 707.
(1) The complaining party has the burden of proving, by a preponderance of the evidence, which grounds exist for the
imposition of a sanction on a licensee, registrant, or applicant.
(2) A petitioner for reinstatement or reclassification of a license or registration has the burden of proving, by clear and
convincing evidence, that the requirements and conditions for reinstatement or reclassification have been satisfied.
(3) An applicant for a license or registration has the burden of proving, by a preponderance of the evidence, that the
pertinent requirements for the license or
registration have been satisfied.
(4) The complaining party has the burden of proving, by a preponderance of the evidence, that grounds exist for the
continuation of a cease and desist order.
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
MICHIGAN ADMINISTRATIVE HEARING SYSTEM
ADMINISTRATIVE HEARING RULES
PART 7: LICENSING AND REGULATORY AFFAIRS HEALTH CODE BOARDS. DISCIPLINARY
PROCEEDINGS – RELEVANT EXCERPT
LARA/BPL-DATACHG/DUPREQ (Rev. 03/20)
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.
1 of 2
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
BPLHelp
DATA CHANGE DUPLICATE LICENSE REQUEST
Authority: 1978 PA 368
PHARMACIES: DO NOT use this form for a name and/or address change. If changing the name of the pharmacy, complete the
Application for Miscellaneous Pharmacy Change form. If the location of the pharmacy has changed, complete the Application for
Pharmacy License form. Both forms can be obtained online.
MANUFACTURER/WHOLESALER: DO NOT use this form for a name and/or address change. Complete an Application for
Manufacturer/Wholesaler License form w
hich can be obtained online.
With the exception of the license types listed above, address changes can also be processed online by visiting our website at
www.michigan.gov/elicense
. However, please use this form when requesting a name change.
NO CHANGES WILL BE MADE IF THIS FORM IS NOT COMPLETE.
Name as it Currently Appears on the License (First, Middle, Last)
Profession
10-Digit MI Permanent ID/License Number (list additional numbers below)
Telephone Number
E-Mail Address
LICENSE/REGISTRATION CHANGE: Please specify which license(s)/registration(s) you want changed.
Professional License/Registration Controlled Substance Specialty License
Drug Control
Drug Treatment Prescriber
If applicable, please list all additional 10-Digit MI Permanent ID/License Numbers requiring a change below:
______________________________________________ _______________________________________________
______________________________________________ _______________________________________________
DUPLICATE LICENSE - $10.00 for EACH license: I request the Department to issue a duplicate license for the following reason:
Data Change Lost Stolen Destroyed
If your license will expire in the next 60 days, you do not need to pay for a duplicate license. You will receive a new license
after the renewal is processed.
Check the License(s)/Registration(s) type below for
which a duplicate license is requested
FOR OFFICE USE ONLY
Professional License/Registration - $10.00
Specialty License - $10.00
Controlled Substance - $10.00
Drug Control - $10.00
Drug Treatment Prescriber - $10.00
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-DATACHG/DUPREQ (Rev. 03/20)
2 of 2
Name as it Currently Appears on the License (First, Middle, Last)
NAME CHANGE: Your signature must be provided below. If you would like a new license reflecting your new name, please see the
fee requirement on page one
.
New Name Requested (First, Middle, Last)
Reason for Change
ADDRESS CHANGE FOR PROFESSIONAL LICENSE/REGISTRATION AND SPECIALTY LICENSE: Your signature must be
provided below. If you would like a new license reflecting your new address, please see the fee requirement on page one.
Name of Office/Facility (if applicable)
New Street Address
City
State
Zip Code
ADDRESS CHANGE FOR CONTROLLED SUBSTANCE, DRUG TREATMENT PRESCRIBER, AND DRUG CONTROL LICENSE:
Your signature must be provided below. If you would like a new license reflecting your new address, please see the fee requirement on
page one.
Name of Office/Facility
New Street Address of Office/Facility
City
State
Zip Code
Signature and Date
(required for name or address change)
I am requesting the Department to change my records due to a name and/or address change as indicated above.
____________________________________________________ ___________________________________
Signature Date
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Completed 9 February 2021

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