.

+|EP|CAL
CLEARANCE
REQUEST
Michigan
Department
of rlumjn
E"-rlI""
Office
of Children
anO nouiili.il;;;
PLEASE
MAIL TO
+
Licensing
Consultant (Name,
Address, phone)
pteted
by
patient)
(ptease print
Completed
by
patient)
!
Adutt Foster
Care (24-Hour
Care)
tr
Child Foster
Care (24-How
C"r"j
!
Chitd Care (Less
Than Z+_Uoi
6,are)
License Application
Type
tr
Capacity
Type
Name (Last,
Firs
or
Date of Birth
Social Security
Number
-
Telephone
Numbei-
INFORMATTON
(To
be
City
State
Zip Code
I authorize
the release.of
medical
information
concerning
me
ts"J;::l"",rf:,ly^,9:q
-1G:"
"#i'
to tn" Michisan
Department
or Humin
services,
6rri";';
cxroi:"i
il,fx3iil
Licensing,
for the Durpose
of Oetermining
my suitabilitv
to
:!Xv;S:
or be associateo
witn *i".ri"'"i
iniroienraependent
Would you
like to be
Physician's
DNo
Yes
TP1,..4"t
116 of 1973 as amended
f-uDtrc Act 219 ot 1g7g as amended
RESPONSE:
PENALTY:
Voluntary
Application
for licensure
may be denied.
Skin Test
t-l X
Pgsitive (Exptain
in Comments
ffi'ffi[l*+*e**u**t$ru*]'ffi
CAI--37{X (tO{S) prevbus
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