Fillable OF APPOINTMENT TO AN ACADEMIC POSITION CLINICAL ACADEMIC (Michigan)

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OF APPOINTMENT TO AN ACADEMIC POSITION CLINICAL ACADEMIC (Michigan)

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File type: PDF

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LARA/BPL-MEDEDLTDRENEW (Rev. 11/18)
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) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
CLINICAL ACADEMIC LIMITED RENEWAL CERTIFICATION
OF APPOINTMENT TO AN ACADEMIC POSITION
Authority: 1978 PA 368
Your license will not be renewed until we receive this information.
Section of Form to be Completed by Applicant:
Licensee’s First Name
Middle Name
Last Name
Social Security Number
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number
Section of Form to be Completed by Program:
Hospital Name or Institution
Hospital or Institution Street Address
City
State
Zip Code
Program Name
Please select one:
Licensee will be continuing their clinical academic appointment in the same program at the same location as shown above
Licensee will be continuing their clinical academic appointment, but will transfer to a new program as shown above
Signature of Director of Medical Education
Date
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OF APPOINTMENT TO AN ACADEMIC POSITION CLINICAL ACADEMIC (Michigan)

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Completed 9 February 2021

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