State of Maryland Department of Labor, Licensing And Regulation
Maryland State Board Of Master Electricians
500 N. Calvert St., Room 302
Baltimore, Maryland 21202-3651
410-230-6163 (Baltimore area) or 1-888-218-5925 (toll free)

Master Electricians Verification Form

Master Electricians Verification Form

INSTRUCTIONS:


I. INDIVIDUAL INFORMATION


FULL NAME  
MIDDLE 
LASTFIRST(IF YOU DO NOT HAVE A MIDDLE NAME ENTER "N.M.N.")
Residence address 
NUMBER AND STREET

CITYCOUNTYSTATE9 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 NO
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.