Transcription of Application for a Medical Doctor, Limited Medical ...
{{id}} {{{paragraph}}}
Example: barber
Application for a Medical Doctor, Limited Medical ...
LARA/BPL-MDNEWRELIC (Rev. 10/17) 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 7 Bureau of Professional Licensing PO Box 30670 Lansing, MI 48909 Telephone: (517) 335-0918 Application FOR Medical DOCTOR, CLINICAL ACADEMIC Limited , EDUCATIONAL Limited LICENSE OR RELICENSURE Authority: 1978 PA 368 Print or Type Clearly Applicant s Name (First Name) (Middle Name) (Last Name) Social Security Number Date of Birth (MM/DD/YYYY) 10-Digit MI Permanent ID/License Number (If Applicable) Address City Stat
I understand that it is the policy of this agency to secure a criminal conviction history as part of the pre- licensure screening process. I authorize this agency to use the information provided in this application to obtain a criminal conviction history
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: