Transcription of Professional Counselor License Application
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Professional Counselor License Application
LARA/BPL-COUNSELAPP (1/18) 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 5 Bureau of Professional Licensing PO Box 30670 Lansing, MI 48909 Telephone: (517) 335-0918 Application FOR A Professional Counselor License Authority: 1978 PA 368 Type or Print Clearly Applicant s First Name Middle Name Last Name Social Security # (New Applicants Only) Date of Birth (New Applicants Only) 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 b
A Professional Disclosure Statement is required from every applicant, even if you are not currently practicing. You must provide a separate Professional Disclosure Statement for each practice location. You are required to submit a new Professional Disclosure Statement to the board within 30 days if you have any changes to the required information.
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