Free Print File - Michigan

BCS/LCE-021 (3/09)

BOARD OFFICE USE ONLY
Process Refer to Enforcement Date: By:

Michigan Department of Energy, Labor & Economic Growth Bureau of Commercial Services Licensing Division P.O. Box 30018, Lansing, MI 48909 517-241-9288 Fax 517-373-3085

REQUEST FOR DISCIPLINARY ACTION INFORMATION
Applicant's Name (Last, First, Middle) Date of Birth

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Social Security Number

Mailing Address (Number and Street) Occupation

City

State

Zip Code

License Type

The following information is required in conjunction with your application for licensure/registration. This is to provide you with an opportunity to explain your affirmative response to the question on your application which asked if you ever had any disciplinary action taken against any license, registration or permit you now hold or have ever held. REPORT ALL DISCIPLINARY ACTION. Use the back of this form or an attachment if you need additional space. If you are unsure of exact details, respond to the best of your knowledge. Failure to provide the information requested may result in the denial of your application. Your name at the time of the disciplinary action. Name of state in which action took place. Date(s) of disciplinary action.

Please describe in detail the action that took place and why.

I hereby certify that the statements and facts provided are true and accurate to the best of my knowledge. Signature Date

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.