Fillable Request for Preliminary Determination (Michigan)

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Request for Preliminary Determination (Michigan)

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LARA/BPL-Preliminary determinationPHC (Rev. 5/19)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or because of race, color, religion, national origin, age, sex, height, weight, marital
status, partisan considerations, or a disability or genetic information that is unrelated to the person’s ability to perform the duties of a particular job or position. If you need
assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
Request for Preliminary Determination
Michigan Public Health Code
Authority: 1978 PA 368
Print or Type Clearly
Applicant’s Legal Name (First Name)
(Middle Name)
(Last Name)
Date of Birth (MM/DD/YYYY)
Profession Name (License or Registration
Address
City
State
Zip Code
Telephone Number
Email Address
List any other name or alias by which you have ever been known, including maiden name, if applicable:
____________________________________________________________________________________
CHECK THE LICENSE/OBTAINED BY METHOD FOR OFFICE USE ONLY
Preliminary determination $75.00 3000
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.
Reference Number
Response Issue Date
Preliminary Determination
Michigan law PA 453 of 2018 (MCL 333.16174a) allows for an individual to obtain a preliminary determination
from the Department concerning whether any court judgements against him or her would likely result in a denial
of a license or
registration for failing to meet the good moral character requirement for that license or registration.
A preliminary determination under this section that is adverse to an individual does not prevent the individual
from subsequently applying for a license or registration in the future. The Department or a Board is not bound
by a preliminary determination under this section if the individual applies for a license or registration under this
act. An individual shall not request more than 1 preliminary determination in any 120-day period.
In evaluat
ing Good Moral Character for licenses issued under the Michigan Public Health Code, the Department
reviews two questions:
1. Have you e
ver been convicted of a felony?
2. 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?
LARA/BPL-Preliminary determinationPHC (Rev.5/19)
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If you would like the Department to make a non-binding preliminary determination concerning whether any court
judgments against you would likely result in a denial of license or registration for failing to meet the good moral
character requirement for that license or registration, please submit a detailed description of the offense(s),
including an explanation of what took place and date(s) of occurrence(s), along with this request form.
To
ensure that the preliminary determination made by the department is an accurate prediction of whether you
will meet the good moral character requirements when applying for a license, you may wish to submit additional
supporting documentation with this request, including court documents and other documentation, if any, that
shows at the current time you have the ability 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 may be seeking a license.
Prelim
inary determinations are based solely upon the information provided and documents submitted with your
request.
Pl
ease note this does not exempt you from the requirement to be fingerprinted for a national criminal history
check from the Federal Bureau of Investigations and Central Records Division of the Michigan State Police at
the time of your formal application.
CERTIFICATION AND SIGNATURE
I understand that the Department or a Board is not bound by a preliminary determination issued if I apply for a
license or registration under this act. The issuance of a preliminary determination under this section does not
limit the authority of the Department to review applications for a license or registration, or to issue or deny a
license or registration.
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.
_______
________________________________________ ___________________________________
Signature of Requestor Date
_______
________________________________________
Printed Name of Requestor
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Request for Preliminary Determination (Michigan)

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Completed 11 January 2021

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