Fillable TO A POSTGRADUATE TRAINING PROGRAM DENTISTRY EDUCATIONAL LIMITED (Michigan)

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TO A POSTGRADUATE TRAINING PROGRAM DENTISTRY EDUCATIONAL LIMITED (Michigan)

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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
DENTISTRY EDUCATIONAL LIMITED LICENSE RENEWAL CERTIFICATION OF APPOINTMENT
TO A POSTGRADUATE TRAINING PROGRAM
Authority: 1978 PA 368
Your license will not be renewed until we receive this information.
Name (First, Middle, Last)
10-Digit MI Permanent ID/License Number
Name of Hospital or Institution
Address of Hospital or Institution
City
State
Zip Code
Program Name
Program Start Date
I am continuing my educational limited appointment in the same program at the same location as shown above.
I am continuing my educational limited appointment, but will transfer to a new program as shown above.
Signature of Director of Medical Education
Date
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TO A POSTGRADUATE TRAINING PROGRAM DENTISTRY EDUCATIONAL LIMITED (Michigan)

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Completed 9 February 2021

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