Professional Engineer - Original Corporate / Partnership / LLC / LLP Permit

Corporation   Partnership   LLP   LLC
This application is for a:                
The following individual is a Maryland professional engineer in good standing and is designated to be the managing agent of this corporation, partnership, LLC or LLP. The managing agent shall be an employee, owner, director officer, member or partner of the entity seeking a permit, and is in a position to act on behalf of the entity in matters related to the practice of or the offering of the practice of engineering.

Managing Agent:
Title:
License Number:
Social Security Number:
(for verification purposes only)
Firm Business Name and Address:
Business Name:
Business Address:
City, State Zip: , -
County:


Licensing Contact:
Contact Person's Name:
Contact Phone No.: - -
Contact Person's Email Address:
Federal ID:    

For Corporation/LLC/LLP Only: Name of State where Corp/LLC/LLP was formed and date of Certificate of formation.
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.

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 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 14, Business Occupations and Professions Article, Annotated Code of Maryland, and the Code of Maryland Regulations, Title 09, Subtitle 23. I further affirm that I understand and accept my responsibilities under such laws and regulations.

    I understand that the managing agent shall be an employee, owner, director, officer, member, or partner of the entity seeking a permit and shall be designated to act on behalf of the entity in matters related to the practice of or the offering of the practice of engineer. In the event the managing agent is no longer affiliated with the entity seeking a permit or there has been a change in the name of the entity, it is the responsibility of the entity to notify the Board within 60 days after the change.

    I understand that by signing this statement, the permit for which I am applying on behalf of the applicant will expire on the date printed on the permit, and that the entity will be required to renew the permit and pay the renewal fee prior to the expiration date. Should the entity fail to renew the permit, the Board may exercise legal actions available to it against the permit holder, including, but not limited to, imposing a fine.


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