State of Maryland Department of Labor, Licensing and Regulation
Maryland Board of Certified Interior Designers
500 N. Calvert St., Room 308
Baltimore, Maryland 21202
(410) 230-6322 (Baltimore area),    (888) 218-5925 (Toll Free)

Verification of Certification/Licensure

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: