Fillable Suspended/Revoked License or Registration Application for Reinstatement of (Michigan)

Fill Online, Printable, Fillable, Blank Suspended/Revoked License or Registration Application for Reinstatement of (Michigan) Form

Use Fill to complete blank online MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Suspended/Revoked License or Registration Application for Reinstatement of (Michigan)

On average this form takes 13 minutes to complete

The Suspended/Revoked License or Registration Application for Reinstatement of (Michigan) form is 8 pages long and contains:

  • 0 signatures
  • 35 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

BROWSE MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
BPLHelp@michigan.gov
LARA/HRD-801(03/20)
Application for Reinstatement of
Suspended/Revoked License or Registration
Authority: PA 368 of 1978
Type or PRINT Clearly
First Name
Middle Name
Last Name
Facility Name (if Applicable)
Street Address
City
State
Zip Code
Telephone Number w/Area Code
Michigan Professional License Number
U.S. Social Security Number
Date of Birth (MM/DD/YY) E-mail address
SIGNATURE
Date
Check the profession for which you are requesting reinstatement. Submit the appropriate fee indicated by the profession. Make
your check or money order payable to the STATE OF MICHIGAN. Do not send cash. Fees are earned upon receipt and can
only be refunded under rules promulgated by the Department.
Please Note: Behavior Analyst, Dentistry, Medicine, Midwifery, Nursing, Optometry, Osteopathic
Medicine, Pharmacy, Physicians Assistants, Podiatry and Veterinary Medicine applications must
be submitted online at: www.michigan.gov/miplus
Please Read Carefully:
1. Submit this application, along with the required supporting documents, to the address shown
above.
2. All supporting affidavits must be originals and must be notarized.
3. All supporting documents must be attached to this application.
4. Submission of copies and/or separate mailing of the supporting documents is not acceptable and
will cause rejection of your application.
5. The proper fee, as listed above, must accompany this application or it will be rejected.
6. A criminal background check is required pursuant to Section 333.16245(8). Instructions will be
provided upon the department’s receipt of this application.
Supporting documents shall establish clear and convincing evidence of compliance with all
applicable criteria set forth in the Guidelines on Reinstatement and, in addition, shall include a
minimum of two (2) affidavits which attest to any or all of the following:
A. that you are of good moral character
,
B. that you are able to resume the practice of your profession with reasonable skill and safety, and
C. that it is in the public interest that your license be reinstated
License Number
Issue Date
ACUPUNCTURIST - $81.10 (54-01-50)
ATHLETIC TRAINER - $81.10 (26-01-50)
AUDIOLOGIST - $129.80 (16-01-50)
D.C. - $27.00 (23-01-50)
M.F.T. - $32.40 (41-01-50)
MASSAGE THERAPY - $21.60 (75-01-50)
N.H.A. - $16.20 (48-01-50)
O.T. - $21.60 (52-01-50)
O.T.A. - $21.60 (52-02-50)
P.T. - $21.60 (55-01-50)
P.T.A. - $21.60 (55-01-50)
PSYCHOLOGIST - $59.45 (63-01-50)
L.L.P. - $59.45 (63-01-50)
L.P.C. - $59.45 (64-01-50)
L.L.P.C. - $59.45 (64-01-50)
R.T. - $21.60 (44-01-50)
SANITARIAN - $27.00 (67-01-50)
SPEECH LANG - $21.60 (71-01-50)
S.S.T. - $16.20 (68-03-50)
L.B.S.W. - $16.20 (68-02-50)
L.M.S.W. - $16.20 (68-01-50)
The statute governing the powers of a notary public reads in pertinent part:
“Notaries public shall have authority to take the proof and acknowledgments of deed; to administer oaths and
take affidavits in any matter or cause pending, or to be commenced….”
The law of the State of Michigan requires that signatures to certain legal instruments (in this case affidavits) be
acknowledged before a person authorized by law to take acknowledgments, such as a notary public. This is
required so that such instruments can be recorded. An example of how an acknowledgment is taken would be as
follows:
John Doe app
ears before a notary public with the unsigned instrument and, in the presence of the notary
public, signs the instrument and then acknowledges to the notary public that the signature on the
instrument is his, that he is the person indicated in the instrument and that he signed the instrument
voluntarily and without duress. The notary public then certifies on the instrument itself that it was
acknowledged in his/her presence. In the certification, the notary public is stating in his/her official
capacity that the person so signing was the person he claimed to be. Obviously, when a notary public is
not familiar with the person whose acknowledgment he/she is certifying, the notary public should request
that some type of identification be shown.
The notary's signature and stamp alone are not sufficient for the affidavit to be
considered notarized by the Department, it must also include the date of signature.
The wording and format of the certification required on each affidavit is shown in the
example below:
Subscribed and sworn to before me this ___1
st
___ day of ________May________, 20_17_.
___(Notary signature here)_____Jane P. Doe______________________________________
Notary Public __(Notary name printed here)_Jane P. Doe____ __(County Name)__County
My Commission expires: _____(12/31/2020)_____
Additional Facts:
1. A notary pub
lic cannot certify the acknowledgment to an instrument to which he/she, himself/herself, has an
interest. A notary public may take the acknowledgement of a relative, including a spouse; however, in order
to avoid questions of conflict of interest, an independent notary public should be used.
2. An affidavi
t is a written or printed declaration or statement of facts. It must be made voluntarily and
confirmed by the oath or affirmation of the party making it, made before a notary public. The notary public
must administer the oath or affirmation prior to the taking of the affidavit.
Affidavits are written statements by individuals, made on oath, before a notary public or other person
authorized to administer oaths. At minimum, an affidavit must contain the following: Signature of
the party making the sworn statement and the date of the signature; signature of notary public and
date notarized; the typed, printed or stamped name of notary; and the state, county and expiration
date of the notary’s commission.
Revised 03/20
Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
AFFIDAVITS INFORMATION SHEET
Please read carefully
PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978
Article 15
OCCUPATIONS
(Full excerpt at: http://legislature.mi.gov/doc.aspx?mcl-368-1978-15)
Links to applicable sections of the Public Health Code:
333.16245 Reinstatement of limited, suspended, or revoked license or
registration; application; payment; time; hearing; guidelines; fee; criminal history
check; permanent revocation.
Sec. 16245 Link: http://legislature.mi.gov/doc.aspx?mcl-333-16245
333.16247 Reinstatement of license or issuance of limited license; requirements.
Sec. 16247 Link: http://legislature.mi.gov/doc.aspx?mcl-333-16247
333.16248 Reinstatement of registration; requirements.
Sec. 16248 Link: http://legislature.mi.gov/doc.aspx?mcl-333-16248
333.16245a Permanent Revocation.
Sec. 16245a Link: http://legislature.mi.gov/doc.aspx?mcl-333-16245a
GUIDELINES ON REINSTATEMENT
In accordance with Section 333.16245(6) of the Public Health Code, 1978 P.A. 368, as amended, the
following guidelines were adopted on November 4, 1996.
1. The
applicant has participated in one or more community service or professional volunteer
activities or programs since the revocation or suspension of his or her license or registration.
2. The
applicant has successfully completed one or more substance abuse treatment programs,
which may include inpatient or outpatient care at a substance abuse facility, regular attendance
at Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings, AA/NA sponsorship,
regular or random witnessed alcohol/drug urine or blood screens, individual or group counseling
or therapy, Caduceus or other professional support group attendance, an agreement with his or
her employer for monitoring, or ongoing review by a primary care physician knowledgeable and
experienced in the treatment of chemical dependency. This criterion applies only if the
applicant’s license or registration was suspended or revoked due to a substance abuse violation.
3. The
applicant has participated in an inpatient or outpatient treatment for mental, psychological,
emotional and/or physical disorders. This criterion applies only if the applicant’s license or
registration was revoked due to a mental, psychological, emotional and/or physical disorder.
4. The
applicant has complied with all terms of his or her order of discipline, including payment of
fines and costs as set forth in said order.
5. The app
licant has successfully completed one or more continuing education programs during the
period of suspension or revocation, or consumed current literature concerning the practice of his
or her particular profession.
6. The applicant has participated in didactic or clinical training, including remedial education in
areas previously found deficient, or successfully completed an overall refresher course if the
applicant has been out of practice for a significant period of time.
7. The
applicant has submitted an assessment or evaluation of the applicant’s professional skills
and knowledge by an individual or entity who is trained or otherwise qualified to make such an
evaluation.
8. The
applicant desires in good faith to be restored to the privilege of practicing his or her
profession in Michigan.
If the
board or task force, in reinstating a license or registration, deviates from the guidelines, the board
or task force shall state the reason for the deviation on the record.
Page 1 of 2
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
MICHIGAN ADMINISTRATIVE HEARING SYSTEM
ADMINISTRATIVE HEARING RULES
PART 7: LICENSING AND REGULATORY AFFAIRS HEALTH CODE BOARDS.
DISCIPLINARY PROCEEDINGS – RELEVANT EXCERPT
R 792.10707 Burden of proof.
Rule 707. (1) The complaining party has the burden of proving, by a preponderance of the evidence, which grounds exist
for the imposition of a sanction on a licensee, registrant, or applicant.
(2) A petitioner for reinstatement or reclassification of a license or registration has the burden of proving, by clear and
convincing evidence, that the requirements and conditions for reinstatement or reclassification have been satisfied.
(3) An applicant for a license or registration has the burden of proving, by a preponderance of the evidence, that the
pertinent requirements for the license or registration have been satisfied.
(4) The complaining party has the burden of proving, by a preponderance of the evidence, that grounds exist for the
continuation of a cease and desist order.
History: 2015 AACS.
R 792.10711 License; registration; duration of suspension; standards and procedures for reinstatement after
revocation or suspension.
Rule 711. (1) The suspension of a license or registration shall continue until the expiration of the period of suspension
set forth in the order or until the license or registration is reinstated pursuant to this rule, whichever is later. The period of
suspension set forth in the order is a minimum period.
(2) A petition for reinstatement of a license or registration that has been suspended or revoked shall be made in
accordance with this rule.
(3) If a license or registration has been suspended for 6 months or less, it will be presumed that the petitioner meets the
requirements of section 7316, 16247(l), or 16248 of the code, MCL 333.7316, MCL 333.16247, or MCL 333.16248,
unless 1 of the following applies:
(a) The order imposing the suspension provides otherwise.
(b) Another complaint has been filed and is pending at the end of the minimum suspension period.
(c) A subsequent disciplinary order has been entered.
(d) A petition with supporting affidavit has been filed by a complaining party alleging that the petitioner has failed to
fulfill a term of the suspension order.
(4) The presumption described in subrule (3) of this rule is made solely for the issue of reinstatement and shall not be
used in any subsequent or collateral proceedings.
(5) If a license or registration has been suspended for more than 6 months, or if the petitioner is not entitled to a
presumption pursuant to subrule (3) of this rule, the license or registration shall not be reinstated until the board or task
force finds that the petitioner meets the requirements of section 7316, 16247, or 16248 of the code, as follows:
(a) The petitioner shall file a petition for reinstatement not sooner than 90 days before the end of the minimum
suspension period. The petition shall be accompanied by supporting affidavits.
(b) Within 30 days after the petition has been filed, a complaining party may file a response to the petition. If the
response opposes the reinstatement, a hearing shall be scheduled. If the petitioner fails to appear at the
scheduled hearing, either in person or by counsel, the petitioner shall be deemed in default. If a response is not
filed, or if the response does not oppose reinstatement, the board or task force shall review the petition with
supporting affidavits and shall determine whether the requirements of section 7316, 16247, or 16248 of the code
have been met. If it is found that the requirements have not been met, the petitioner shall be notified and, within
30 days after service of the notice, may request a hearing. The petition for reinstatement shall be deemed denied
if the petitioner does not file a timely request for a hearing.
(6) A petition for reinstatement of a revoked license or registration shall be considered in accordance with the standards
and procedures set forth in subrule (5) of this rule. The petition shall not be accepted sooner than 3 years after the
effective date of the revocation, except that where the license or registration was revoked pursuant to section
16221(b)(vii) or (c)(iv) of the code, MCL 333.16221, for a felony conviction or was revoked for any other felony conviction
involving controlled substances, the petition shall not be accepted sooner than 5 years after the effective date of the
revocation. A period of summary suspension is not included in calculating the revocation period.
Page 2 of 2
(7) Before reinstating a license or registration, the board or task force shall consider the following in assessing a
petitioner's ability to practice and the public interest:
(a) The board or task force shall determine whether the petitioner has complied with the guidelines adopted by the
department pursuant to section 16245(6) of the code, MCL 333.16245. If, in reinstating the license or registration,
the board or task force deviates from the guidelines, it shall state in its order the reasons for the deviation.
(b) If the disciplinary subcommittee's final order included corrective measures, remedial education, or training as a
condition of reinstatement, the board or task force shall consider the extent of the petitioner's compliance with the
conditions set forth in the final order. In addition, the board or task force may impose other requirements for
reinstatement as deemed appropriate, including additional training, education, or supervision.
(c) If the final order of the disciplinary subcommittee did not address corrective measures, remedial education, or
training as a condition of reinstatement, the board or task force, in determining a petitioner's ability to practice safely
and competently, may consider the need for additional training and education in determining if the petitioner has met
the criteria established in section 16247(l) of the code, MCL 333.16247(1).
(8) After a hearing has been completed, the board or task force shall determine whether the petitioner has satisfied
section 7316, 16247, or 16248 of the code MCL 333.7316, MCL 333.16247, or MCL 333.16248. The board or task force
may deny the petition or grant the petition subject to terms and conditions that it deems appropriate.
(9) A subsequent petition for reinstatement may not be filed with the bureau for at least 1 year after the effective date of
the order denying reinstatement.
History: 2015 AACS.
Courtesy of www.michigan.gov/orr
LARA/BPL-DATACHG/DUPREQ (Rev. 03/20)
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.
1 of 2
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
BPLHelp
DATA CHANGE DUPLICATE LICENSE REQUEST
Authority: 1978 PA 368
PHARMACIES: DO NOT use this form for a name and/or address change. If changing the name of the pharmacy, complete the
Application for Miscellaneous Pharmacy Change form. If the location of the pharmacy has changed, complete the Application for
Pharmacy License form. Both forms can be obtained online.
MANUFACTURER/WHOLESALER: DO NOT use this form for a name and/or address change. Complete an Application for
Manufacturer/Wholesaler License form w
hich can be obtained online.
With the exception of the license types listed above, address changes can also be processed online by visiting our website at
www.michigan.gov/elicense
. However, please use this form when requesting a name change.
NO CHANGES WILL BE MADE IF THIS FORM IS NOT COMPLETE.
Name as it Currently Appears on the License (First, Middle, Last)
Profession
10-Digit MI Permanent ID/License Number (list additional numbers below)
Telephone Number
E-Mail Address
LICENSE/REGISTRATION CHANGE: Please specify which license(s)/registration(s) you want changed.
Professional License/Registration Controlled Substance Specialty License
Drug Control
Drug Treatment Prescriber
If applicable, please list all additional 10-Digit MI Permanent ID/License Numbers requiring a change below:
______________________________________________ _______________________________________________
______________________________________________ _______________________________________________
DUPLICATE LICENSE - $10.00 for EACH license: I request the Department to issue a duplicate license for the following reason:
Data Change Lost Stolen Destroyed
If your license will expire in the next 60 days, you do not need to pay for a duplicate license. You will receive a new license
after the renewal is processed.
Check the License(s)/Registration(s) type below for
which a duplicate license is requested
FOR OFFICE USE ONLY
Professional License/Registration - $10.00
Specialty License - $10.00
Controlled Substance - $10.00
Drug Control - $10.00
Drug Treatment Prescriber - $10.00
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.
LARA/BPL-DATACHG/DUPREQ (Rev. 03/20)
2 of 2
Name as it Currently Appears on the License (First, Middle, Last)
NAME CHANGE: Your signature must be provided below. If you would like a new license reflecting your new name, please see the
fee requirement on page one
.
New Name Requested (First, Middle, Last)
Reason for Change
ADDRESS CHANGE FOR PROFESSIONAL LICENSE/REGISTRATION AND SPECIALTY LICENSE: Your signature must be
provided below. If you would like a new license reflecting your new address, please see the fee requirement on page one.
Name of Office/Facility (if applicable)
New Street Address
City
State
Zip Code
ADDRESS CHANGE FOR CONTROLLED SUBSTANCE, DRUG TREATMENT PRESCRIBER, AND DRUG CONTROL LICENSE:
Your signature must be provided below. If you would like a new license reflecting your new address, please see the fee requirement on
page one.
Name of Office/Facility
New Street Address of Office/Facility
City
State
Zip Code
Signature and Date
(required for name or address change)
I am requesting the Department to change my records due to a name and/or address change as indicated above.
____________________________________________________ ___________________________________
Signature Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

SuspendedRevoked License or Registration Application for Reinstatement of (Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document