State of Maryland Department of Labor
Maryland State Board Of Public Accountancy
1100 N. Eutaw St
Baltimore, Maryland 21201
(410) 230-6322 (Baltimore area),    (888) 218-5925 (Toll Free)

Verification of Licensure Form For Limited License



I. Candidate must complete this section (please type):

Name
Address
City , State Zip Code
Daytime Telephone No.
Email Address


I, , am applying for a Limited License to the State of Maryland, based upon my
License number: _
Date Issued: _
By the State of _ .


_
Signature


Note to applicants: Upon completion of Section I, please forward this form to the state board from which you obtained your original license. Include a postage paid, addressed envelope for return to the Maryland Board.




II. THIS SECTION MUST BE COMPLETED BY THE STATE BOARD FROM WHICH YOU OBTAINED THE ORIGINAL LICENSURE (please circle the appropriate answer).


  1. Is the applicant's license in good standing? [ Yes ] [ No ]

  2. Are the License number and date of issue correct? [ Yes ] [ No ]

  3. Date of expiration of license: _



Board Seal Signature _

Title _

Date _