CERTIFICATION OF MEDICAL EDUCATION FOR ... - Michigan
Bureau of Professional Licensing
PO Box 30670 ¡ñ Lansing, MI 48909
Telephone: (517) 335-0918
bpl
BPLData@
CERTIFICATION OF MEDICAL EDUCATION
FOR GRADUATES OF MEDICAL SCHOOLS LOCATED IN THE UNITED STATES,
ITS TERRITORIES, THE DISTRICT OF COLUMBIA OR THE DOMINION OF CANADA
Authority: 1978 PA 368
This form is intended for use by Medical Doctor (MD) license types only. This form must be submitted directly to this office by the
dean or registrar of medical school. If this form is submitted by the applicant, it will not be accepted.
Applicant Information:
Applicant¡¯s First Name
Middle Name
Last Name
Date of Birth (MM/DD/YYYY)
Address
City
State
Zip Code
Telephone Number
Email Address
Name of Medical School
Type of License Applying for (check appropriate box below):
MD Educational Limited License
MD Full License
Remainder of Form to be Completed by the Dean or Registrar of the Medical School
Name of Medical School
Address of Medical School
City
State
Zip Code
CERTIFICATION AND SIGNATURE
I certify the applicant named above was / will be granted the Degree of Medical Doctor / Doctor of Medicine/ MD on
_____________________________.
(Month/Day/Year)
_________________________________________________
Signature of Dean or Registrar
________________________________________
Date
_________________________________________________
Print or Type Name of Dean or Registrar
(Seal)
NOTE: Form will not be accepted if submitted more than 3 months prior to graduation and/or the date of application for licensure.
LARA/BPL-MEDCERTEDUS (Rev. 4/2021)
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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