LARA/BPL-BEHAVIORTECHVERIF (2/20)
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.
VERIFICATION OF SUPERVISION FOR ASSISTANT BEHAVIOR ANALYST
Authority:
1978 PA 368
The supervisor signing this form must be a Michigan licensed behavior analyst. A separate form must be submitted for each
supervisor who is verifying they supervise you.
Section of Form to be Completed by Applicant:
Legal Name (First, Middle, Last)
Telephone Number with Area Code
E-mail Address
Remainder of Form to be Completed by Supervisor:
Name of Organization where Applicant is Employed
Supervisor’s Printed Name (First, Middle, Last)
Michigan Behavior Analyst License Number
7401-
CERTIFICATION AND SIGNATURE
I certify the applicant named above is under my supervision and that as the supervisor I am licensed in the state of Michigan
as a Behavior Analyst, I am certified and in good standing with the BACB and all supervision provided complies with current
BACB supervision requirements.
_____________________________________________
_________________ ________________________________________________
Signature and Title Date
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
bpldata@michigan.gov
