LARA/BPL-VOLLIC (Rev.5/19)
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.
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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
SPECIAL VOLUNTEER LICENSE APPLICATION
Authority: 1978 PA 368
Print or Type Clearly
Applicant’s First Name
Middle Name
Last Name
U.S. Social Security Number
Date of Birth (MM/DD/YYYY)
10-Digit MI Permanent ID/License Number
Expiration Date of License (
MM/DD/YYYY)
Address
State
Zip Code
Country
Email Address
List any other name or alias by which you have ever been known, including maiden name, if applicable:
____________________________________________________________________________________
CHECK ONE PROFESSION
Acupuncturist
Athletic Trainer
Audiologist
Chiropractor
Dentist
Dental Specialty Endodontist
Dental Specialty Orthodontist
Dental Specialty Pediatric
Dental Specialty Periodontist
Dental Specialty Prosthodontist
Dental Specialty Oral Surgeon
Registered Dental Assistant
Registered Dental Hygienist
Marriage and Family Therapist
Massage Therapist
Medical Doctor
Licensed Practical Nurse
Registered Nurse
R.N. Specialty Nurse Anesthetist
R.N. Specialty Nurse Midwife
R.N. Specialty Nurse Practitioner
Nursing Home Administrator
Occupational Therapist
Occupational Therapy Assistant
Optometrist
Osteopathic Physician
Pharmacist
Pharmacy Technician
Physical Therapist
Physical Therapy Assistant
Physician’s Assistant
Podiatrist
Professional Counselor
Master’s Limited Psychologist
Psychologist
Respiratory Therapist
Sanitarian
Social Service Technician
Bachelor’s Social Worker
Master Social Worker
Speech Language Pathologist
Veterinarian
Veterinary Technician
Controlled Substance License(coincides with profession)
Fees: $ 90.15 (1 Year) 5315-13757
$169.70 (2 Years) 5315-23757
$249.25 (3 Years) 5315-33757
FOR OFFICE USE ONLY
License Number
Issue Date
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?
LARA/BPL- VOLLIC (Rev. 5/19)
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CERTIFICATION AND SIGNATURE
I confirm that I have retired from engaging in active practice of a health profession and that I am now applying for a
special volunteer license. This license will be utilized to donate my expertise for the health care and treatment of indigent
and needy individuals in this state or for the health care and treatment of individuals in medically underserved areas of
this state.
I understand that I will be subject to all the provisions of the Public Health Code regarding licensure including continuing
education requirements and disciplinary action if I am granted a special volunteer license.
I affirm that I will not receive any payment or compensation, either direct or indirect, or have the expectation of any
payment or compensation for any health care and treatment services provided by me under the special volunteer license
and I will not engage in activities outside the scope of practice of the profession for which I was licensed prior to retirement.
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.
Further, by signing below, I certify that I have completed the required number of continuing education credits.
_______________________________________________ ___________________________________
Signature of Licensee Date
_______________________________________________
Printed Name of Licensee
Required Additional Documents:
All Applicants
There is no fee for the special volunteer license. However, there is a fee for a controlled substance license, if the
applicant is authorized to hold a controlled substance license and needs it to provide services with the special
volunteer license.
If you have been out of practice for 3 years or more and you were licensed in a profession with continuing education
requirements for renewal, you must submit proof of completing 2/3 of the required continuing education courses
completed during the 3 years immediately preceding this application. Information regarding continuing education
may be found at www.michigan.gov/healthlicense
and click on your specific profession, then under “Licensing
Information” click on “CE Requirements”.
An individual is considered retired from engaging in the practice of a health profession if the individual’s license has
expired with the individual’s intention of ceasing to engage, for remuneration, in the practice of the health profession.