MICHIGAN NURSING SCHOOL CERTIFICATION Authority: 1978 PA 368 If This Form Is Not Completed, a License Will Not Be Issued

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MICHIGAN NURSING SCHOOL CERTIFICATION Authority: 1978 PA 368 If This Form Is Not Completed, a License Will Not Be Issued

Bureau of Professional Licensing PO Box 30670 ● Lansing, MI 48909 Telephone: (517) 241-0199 www.michigan.gov/bpl [email protected] MICHIGAN NURSING SCHOOL CERTIFICATION Authority: 1978 PA 368 If this form is not completed, a license will not be issued The Dean, Director, or Registrar of a nursing program in Michigan completes the information below and submits this certification directly to the Michigan Board of Nursing at [email protected] in a PDF. Out-of-state and Canadian Applicants do not use this form. They MUST have their nursing school submit final official transcripts, showing the degree earned and graduation date via USPS to the address listed above or use a digital credential service and send to [email protected]. Print or Type Student’s First Name Middle Name Last Name Student’s Social Security Number Student’s Date of Birth (MM/DD/YYYY) Name of Nursing School where Student Graduated from Program Code Location of Nursing School Nursing Program Completion Date (this is the date we will use to make the student eligible to take the NCLEX) (Month/Day/Year) I further certify that the applicant has fulfilled all requirements for: Licensed Practical Nurse (LPN) Registered Nurse (RN) Certificate Associate Degree Bachelor Degree Conferred Date: __________________________________________________________. This is the graduation/commencement date (Month/Day/Year) ___________________________________________ ___________________________________ Signature of Dean, Director, or Registrar Date of Signature ___________________________________________ Type or Print Name of Dean, Director, or Registrar LARA/BPL-Nursing (Rev. 1/2020) 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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