State of Maryland Department of Labor Maryland Board of Certified Interior Designers 100 S. Charles St, Tower 1, 3rd Floor Baltimore, Maryland 21201 (410) 230-6322 (Baltimore area),    (888) 218-5925 (Toll Free)

I. APPLICANT MUST COMPLETE THIS SECTION:

BOARD OF PRIOR CERTIFICATION/LICENSURE   ADDRESS

(NAME OF APPLICANT) (STREET ADDRESS)   (CITY)           (STATE)   (ZIP) Social Security No: _______________________

II.	THE BOARD OF PRIOR CERTIFICATION/LICENSURE MUST COMPLETE THIS SECTION:
	The above named person was certified/licensed as follows:
	1. was certified/licensed as a Certified Interior Designer on , 19, and was issued Certificate Number License Number   2. now holds a valid certification/license which expires on unless renewed.   3. held a valid certification/license which expires on .   4. was granted the above certification/license (a) by practice in the State at the time of passage of Law   (b) by reciprocity with the State of   (c) by written examination hrs.   (d) other   5. the written exam was completed on   DATE

PLEASE COMPLETE ALL OF THE FOLLOWING INFORMATION:

EXAMINATION SUBJECT	NUMBER OF HOURS	PASSING GRADE	DATE PASSED	NCIDQ EXAM

BY:		(BOARD SEAL)
	TYPE OR PRINT
	SIGNATURE
TITLE:
DATE: