Master Electricians Verification Form

State of Maryland Department of Labor
Maryland State Board Of Master Electricians
1100 N. Eutaw St
Baltimore, Maryland 21202-3651
410-230-6163 (Baltimore area) or 1-888-218-5925 (toll free)

INSTRUCTIONS:

Reciprocity, State - Local: Applicant must complete Sections I and II and then forward form to the local jurisdiction, which will then complete Sections IV and V and return it directly to the Maryland State Board of Electricians.
Reciprocity, Interstate: Applicant must complete sections I and III and then forward form to the State Licensing Board from which you obtained your original license by examination, which will then complete Sections IV and V and return it directly to the Maryland State Board of Electricians.

I. INDIVIDUAL INFORMATION

FULL NAME


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

Residence address


NUMBER AND STREET

CITY

COUNTY

STATE

9 DIGIT ZIP CODE REQUIRED

Residence telephone no. Business telephone no.

II. RECIPROCITY, STATE - LOCAL

I am applying for a State Master Electrician License based upon holding a current license with a local jurisdiction within Maryland:
License Number:

Local Jurisdiction (City or County):

Effective date of first license:

III. RECIPROCITY, INTERSTATE

I am applying for a state Master Electrician license based upon holding a current license with another state:
License Number:

State:

Effective date of first license:

Do you hold an electrical license in any other local jurisdiction, state or District of Columbia? (If yes, please list other jurisdiction with license number)

YES

License Number:

State / Local Jurisdiction:

Effective date of first license:

IV. LICENSE INFORMATION. To be completed by the city, county, or state from which applicant obtained original license by examination.
(1)	Is the applicant's certificate in good standing? Date of expiration ____________	YES NO

(2)	Are the license number, date of issue and other pertinent facts on this form correct?	YES NO

(3)	Period of consecutive licensure by applicant immediately prior to this date: _____ Less than 1 year; _____ 1 year; _____ 2 years or more.

(4)	Did the applicant obtain the license by examination?	YES NO

(5)	If yes, date applicant passed the examination: month __________ year _____________

(6)	Has applicant ever been charged with a violation of the local or state Board's electrical laws or regulations?	YES NO

(7)	If YES, please submit the date(s) and type(s) of offense(s) on the back of this form.

(8)	Name of licensed company as appears on local license: ______________________________________________________________
(9)	Is the applicant qualified to contract to provide electrical services?	YES NO

V. I do solemnly declare and affirm under the penalty of perjury that the contents of this document are true and correct.

Name

Board Seal
Signature

Title

Board Name

Date

THIS FORM MUST BE COMPLETED BY THE LOCAL OR STATE BOARD AND FORWARDED DIRECTLY BY THEM TO THE MARYLAND BOARD OF MASTER ELECTRICIANS AT THE ABOVE ADDRESS.