Get MI BCS/LPI-040 2011-2024

O. Box 30018 Lansing MI 48909 517-241-8720 www. michigan.gov/pi PERSONAL REFERENCE FORM AUTHORITY P. BCS/LPI-040 04/11 Michigan Department of Licensing and Regulatory Affairs Bureau of Commercial Services Licensing Division PROFESSIONAL INVESTIGATOR P. A. 285 of 1965 as amended P. A. 330 of 1968 as amended COMPLETION Voluntary PENALTY Failure to complete may result in denial of the applicant s application To complete this form you must have known the applicant for at least five years and not be related by birth or marriage. Name of Applicant How long have you known How often do you see the applicant at the present time Are you related Upon which of the following conditions is your acquaintance based Yes No Does the applicant use intoxicants to excess Educational Has the applicant ever been arrested or involved in any trouble Yes - Please explain on reverse side Social Neighbor Business property To the best of your knowledge has the applicant demonstrated any characteristics unbecoming or inappropriate for the type of license for which he/she is applying. List where the applicant has been employed during the past 10 years if it is known to you. A. B. C. D. NOTE Feel free to include any further information or additional remarks on the reverse side of this form* Name of Reference Please Print Home Address Number Street Occupation or Title City State Zip Code Home Telephone Number Business Address Number Street Business Telephone Number Date Signature NOTE THIS FORM MUST BE NOTARIZED. STATE OF MICHIGAN COUNTY OF SS* Subscribed and Sworn to before me this day of Year Name of Notary County Commission Expires Signature of Notary Public Type Print or Stamp LARA is an equal opportunity employer/program* Auxiliary aids services and other reasonable accommodations are available upon request to individuals with disabilities. A. 285 of 1965 as amended P. A. 330 of 1968 as amended COMPLETION Voluntary PENALTY Failure to complete may result in denial of the applicant s application To complete this form you must have known the applicant for at least five years and not be related by birth or marriage. Name of Applicant How long have you known How often do you see the applicant at the present time Are you related Upon which of the following conditions is your acquaintance based Yes No Does the applicant use intoxicants to excess Educational Has the applicant ever been arrested or involved in any trouble Yes - Please explain on reverse side Social Neighbor Business property To the best of your knowledge has the applicant demonstrated any characteristics unbecoming or inappropriate for the type of license for which he/she is applying. Name of Applicant How long have you known How often do you see the applicant at the present time Are you related Upon which of the following conditions is your acquaintance based Yes No Does the applicant use intoxicants to excess Educational Has the applicant ever been arrested or involved in any trouble Yes - Please explain on reverse side Social Neighbor Business property To the best of your knowledge has the applicant demonstrated any characteristics unbecoming or inappropriate for the type of license for which he/she is applying. List where the applicant has been employed during the past 10 years if it is known to you. A. B. C. .