LARA/BPL- VOLLIC (Rev. 5/19)
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Continuing Education
Have you been out of practice 3 or more years? Yes No
If yes, ha
ve you attended at least 2/3 of the required continuing education courses or
programs
required to renew your license during the 3 years immediately preceding this application? Yes No
Good Moral Character Questions
If you answer “yes” to either of the next two questions, you must submit a written explanation as to what took place
including date(s) of occurrence(s), court documents, documentation which shows at the current time you have the ability
to, 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 are seeking a license.
Answering “yes” to the following question may not automatically prevent you from obtaining a license. In evaluating your
good moral character, the department will consider whether the substance of your former offense is reasonably related to
the profession to which you are seeking a license. Also, please know that you may request a preliminary determination
from the Department concerning whether any court judgments against you would likely result in a denial of a license for
failing to meet the good moral character requirement. More information about requesting a preliminary determination can
be found at www.michigan.gov/healthlicense .
Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a misdemeanor punishable by imprisonment for a maximum Yes No
term of two years or a misdemeanor involving the illegal delivery, possession, or use of alcohol
or a controlled substance?
License(s) in Other State(s) and/or Country
List each state or country where you have ever held a health profession license, the license number, the date issued, how
the license was obtained, and whether sanctions have ever been imposed against that license or registration.
(Attach additional sheets if necessary)
If you indicate there have been sanctions imposed against a license or registration, you must disclose the applicable state(s)
and/or country. Submit documentation that the sanction in the other state(s) and/or country is not permanent, that it was not
the result of a patient safety violation, and if you were required by the state(s) and/or country that imposed the sanction to
participate in and complete a probationary period, a treatment plan as a condition of the continuation of your licensure that
it was completed or you did not complete the probationary period or treatment plan because you ceased engaging in the
practice of medicine in that state(s) and/or country.
State/Country
Permanent
License/Registration
Number
Date of Issuance
How Obtained
(Examination/
Endorsement)
Have You Ever Had
Sanctions Imposed
Against this
License/Registration?
