HVACR - Endorsement of Employer

STATE OF MARYLAND

Department of Labor
Maryland State Board of HVACR
100 S. Charles St, Tower 1, 3rd Floor
Baltimore, Maryland 21201
410-230-6159 (Baltimore area) or 1-888-218-5925 (toll free)

This blank form may be photocopied as needed for additional certificates.
It is suggested that you make and retain photocopies of the signed,
completed form(s) for your own records.

Note: If you have not been continuously employed by the same employer, a similar form must be completed for each employer indicating hours worked.

Applicant's Full Name:

Address:

Street

City

State

Zip Code

Social Security Number:

Note: The following sections must be completed by the employer.

Served as a

Journeyman

Apprentice

FROM

HOURS

Month

Day

Year

Month

Day

Year

Month

Day

Year

Month

Day

Year

Month

Day

Year

Month

Day

Year

TOTAL HOURS WORKED

Please provide a detailed description of what types of work the employee was responsible to handle in each of the four following areas. Each area must be addressed separately. Attach additional sheet(s) where you find it necessary to expand on any of the four areas.

HEATING

Hydronic Work
Forced Air Work
Other Heating Work

VENTILATION

AIR CONDITIONING

Cooling Work
Heat Pump Work

REFRIGERATION

Did the employee work at the equivalent of a Journeyman/Apprentice level or above in each of the above areas during employment with you?

Yes

If "No", please provide comment as to the employee's level of work in each of the categories:

Any additional comments as the employee's overall capability in HVACR work:

Name of Employer:
Job Title:			Maryland HVACR License Number:

Company Name:

Company Address:

Street

City

State

Zip Code

Name of Person
Completing this Reference:

I certify under penalty of perjury that the applicant named above served as a journey or apprentice HVACR under my direction and supervision for the time(s) indicated.

SIGNATURE OF PERSON COMPLETING THIS REFERENCE
Date Signed
Job Title			Telephone Number