Master Electricians Verification Form
|I. INDIVIDUAL INFORMATION|
|CITY||COUNTY||STATE||9 DIGIT ZIP CODE REQUIRED|
|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 NO|
|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
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.