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)

Note: This form is a supplement to the information that you previously submitted online through the Internet.


I hereby apply for a license by reciprocity as a Certified Public Accountant of Maryland, based on my License Number Dated , as a Certified Public Accountant of the State of , and now in full force and effect, in accordance with the provisions of Business Occupations and Professions Article, Title 2 of the Annotated Code of Maryland.

FULL NAME

MIDDLE  LAST FIRST (IF YOU DO NOT HAVE A MIDDLE NAME ENTER "N.M.N.")

RESIDENCE ADDRESS (Street)
City	County
State	9 Digit Zip Code
Home Telephone No.	Business Telephone No.
Social Security No.

EDUCATION TRANSCRIPTS: Applicant shall furnish to the Board, with the application (if not previously submitted) an official transcript (raised seal and registrar's signature) of all undergraduate and graduate work. Copies will not be accepted. Transcripts must show all required courses completed and degree granted.

List names of institutions and degrees or certificates received with dates:

Name and Location	From	To	Degree Earned (Type)

YOU MUST SUBMIT A VERIFICATION OF LICENSURE FORM TO THE STATE FROM WHICH YOU OBTAINED ORIGINAL LICENSURE.

If you have not completed an Ethics Examination, contact the AICPA at 1-800-862-4272 to obtain the Home Study Course in Professional Ethics for Certified Public Accountants. A copy of the certificate of completion of the ethics examination must be submitted with your application.

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.

Signature of Application: Date Signed:

FOR OFFICIAL USE ONLY

APPROVED BY:	DATE
DENIED BY:	DATE
REASON FOR DENIAL: