CPA - Transfer of Grades Application


Full Name:



, -
County:


- - (MM-DD-YYYY)
Place of Birth:

and : ,

:
- -

1. Have you ever been convicted of a felony or misdemeanor in any State, District of Columbia or Federal court?
2. Have you ever had this type of license denied, suspended, or revoked by Maryland, any other State or the District of Columbia?
3. Have you been convicted of or received probation before judgment of any drug offense committed after January 1,1991?

 I have Workers Compensation Coverage   Policy/Binder No.

Issued by the  

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


Certification

By pressing "Submit" below:

    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, Licensing and Regulation 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, Licensing and Regulation or have provided for payment in a manner satisfactory to the unit responsible for collection.



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