CERTIFICATION OF APPOINTMENT TO AN ACADEMIC ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Applicant Information section. Enter the applicant’s first name, middle name, last name, date of birth, and the last four digits of their Social Security Number. If this is a renewal, include the Michigan Educational Limited License Number.
3. Next, move to the section for the Director of Medical Education. Fill in the name and address of the training hospital, including city, state, and zip code.
4. If applicable, enter the ACGME/AOA/CPME Program Number. This information is crucial for proper accreditation.
5. In the Certification and Signature section, ensure that you accurately certify the applicant's appointment details including program name and start date.
6. Select the appropriate box indicating accreditation type (MD ONLY, DO ONLY, or PODIATRY ONLY) based on your program.
7. Finally, have the Director of Medical Education sign and print their name along with the date. If there is no hospital seal, indicate that as well.

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