Land Surveyor - Original Corporate / Partnership / LLC / LLP Permit

This application is for a:

President/Partner Name:

Resident Agent Name::
City, State Zip: , -

Corp./Partnership/LLC/LLP Name:
Business Address:
City, State Zip: , -
County of Business Address:
Contact Phone No.: - -
Contact Person Email Address:

Federal ID:
For Corporation/LLC/LLP Only: Name of State in which incorporated and date of Certificate of incorporation.
State: Date: --

 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.


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.

    I affirm that I have carefully read the laws and regulations set forth in Title 15, Business Occupations and Professions Article, Annotated Code of Maryland, and the Code of Maryland Regulations, Title 09, Subtitle 13. I further affirm that I understand and accept my responsibilities under such laws and regulations.

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