LARA/BPL-SSNAFFIDAVIT (Rev. 10/19)
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
SOCIAL SECURITY NUMBER AFFIDAVIT FOR LICENSURE
Required Information:
Legal Name (First, Middle, Last)
License Type
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number, if applicable
iEmail Address
Pursuant to MCL 338.3434a of the Regulated Occupation Support Enforcement Act, 1996 PA 236, and MCL 333.16177 of the
Michigan Public Health Code, 1978 PA 368, an individual applying for licensure is required to provide his or her social
security number at the time of application. You must provide your social security number to the Department in writing.
This requirement does not apply to an applicant who demonstrates he or she is exempt under law from obtaining a social
security number or to an applicant who for religious convictions is exempt under law from disclosure of his or her social security
number under these circumstances.
Applicant’s Social Security Number:
If you do not have a social security number you must provide a reason and complete the attestation below:
Social Security Number Waiver:
I attest/certify that I do not have a social security number and provide the written statement below attesting to that fact with
the reason for which I do not have a social security number.
I further certify that the reason I do not have a U.S. Social Security Number is true and complete. I hereby affirm that I will
provide my U.S. Social Security Number to the Department of Licensing and Regulatory Affairs upon receipt. I
understand that any misrepresentation or fraud may be cause for denial of my application, disciplinary action, or may be
punishable by law.
Written statement and reason for not having a Social Security Number:
