CPA - Transfer of Grades Application


Full Name:



, -
County:


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

and : ,

:
- -

Have you ever:
1. Been convicted of a felony or misdemeanor in any State or Federal Court?
2. Had this type of license, certificate, registration, or permit denied, suspended, or revoked by Maryland or any other jurisdiction?

 
 

 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.
    In accordance with Executive Order 01.901.1983-18, the Department of Labor, Licensing and Regulation 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 user 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.



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