Issued by the  

 I am not an employer required to provide employee coverage under the Workers Compensation Law.

Certification

I hereby certify, under penalty of perjury, that the information contained herein is true and correct to the best of my knowledge, information, and belief. I further authorize the release of any information contained within this application to an authorized representative of the Department of Labor for further investigation. I further certify that I have paid all undisputed taxes and unemployment insurance contributions payable to the Comptroller or the Department of Labor or have provided for payment in a manner satisfactory to the unit responsible for collection.

In accordance with Executive Order 01.901.1983-18, the Department of Labor is required to advise you as follows regarding the collecting of personal information: Personal information requested by the licensing agency of the Department is necessary in determining your eligibility for licensure. Such personal information is also intended for use as an additional means of verifying the licensee’s identity or to enable the agency to communicate, in a timely manner, with the licensee should the need arise. The licensee has a right to inspect his/her personal record and to amend or correct the personal data if necessary. Personal information is generally available for inspection by the public only in accordance with the Public Information Act. Personal information is not routinely shared with state, federal or local government agencies.

I affirm that I have carefully read the laws and regulations set forth in Title 3, Business Occupations and Professions Article, Annotated Code of Maryland, and the Code of Maryland Regulations, Title 09, Subtitle 21. I further affirm that I understand and accept my responsibilities under such laws and regulations.

Also, I understand that at least two-thirds of the directors (corporations), partners (partnerships), general partners (LPs) or members (LLCs) must be licensed in Maryland or another state to practice architecture, engineering, or landscape architecture and that this composition must be maintained at all times in order to remain in compliance with the Maryland Architects Act, Business Occupations and Professional Article 3-404.