State of Maryland Department of Labor Maryland Board of Examiners of Landscape Architects 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 (TYPE) TO: STATE BOARD

NAME OF APPLICANT STREET ADDRESS CITY STREET ZIP SOCIAL SECURITY NUMBER

SECTIONS II - V FOR COMPLETION BY BOARD OF PRIOR LICENSURE

II. THE ABOVE NAMED PERSON WAS LICENSED AS A LANDSCAPE ARCHITECT:
NUMBER ISSUED	DATE ISSUED	VALID UNTIL	DATE APPLIED
III. MINIMUM REQUIREMENTS WERE:

PLEASE COMPLETE ALL OF THE FOLLOWING INFORMATION

EXAMINATION SUBJECT	NUMBER OF HOURS	PASSING GRADE	DATE PASSED	CLARB EXAM?

	1.		Oral Examination  Written Examination
	2.		The above license was granted by reciprocity with the State of
	3.		OTHER: Please give full details on page 2 of this form.

IV.		PLEASE USE PAGE 2 OF THIS FORM FOR FURTHER EXPLANATION OR COMMENTS.
V.		INDIVIDUAL HAS BEEN THE SUBJECT OF DISCIPLINARY ACTION BY THIS BOARD. PLEASE INCLUDE COPY OF FINAL ORDER IN THE MATTER.
		BY:        (BOARD SEAL) TITLE: DATE: NOTE TO APPLICANTS: Include a postage paid, addressed envelope for return to Maryland Board