Transcription of APPLICATION FOR OCCUPATIONAL THERAPIST AND …
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APPLICATION FOR OCCUPATIONAL THERAPIST AND …
LARA/BPL-OTNew/Relic (Rev. Date 12/17) 1 of 5 Bureau of Professional Licensing PO Box 30670 Lansing, MI 48909 Telephone: (517) 335-0918 APPLICATION FOR OCCUPATIONAL THERAPIST AND OCCUPATIONAL THERAPY ASSISTANT LICENSURE AND RELICENSURE Authority: 1978 PA 368 Print or Type Clearly Applicant s 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 State Zip Code Country Telephone Number Email Address List any other name or alias by which you have ever been known, including maiden name, if applicable: _____ CHECK THE LICENSE/OBTAINED BY METHOD FOR OFFICE USE ONLY OCCUPATIONAL THERAPIST By Endorsement $ 5 201-09 Occupati
List each state or country where you have ever held an occupational therapy license, the license or registration number, the date issued, how the license was obtained, and whether sanctions have ever been imposed against that license or
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