State of Maryland Department of Labor, Licensing And Regulation
Maryland State Board Of Plumbing
500 N. Calvert St., Room 302
Baltimore, Maryland 21202-3651
410-230-6164 (Baltimore area) or 1-888-218-5925 (toll free)

Plumbers - Endorsement of Employer

Plumbers - Endorsement of Employer

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 Master Plumber, a similar form must be completed for each employer indicating hours worked.
Applicant's Full Name:
Social Security Number:
Served as a     Journey Plumber      Apprentice
FROM
TO
HOURS


Month


Day


Year


Month


Day


Year
 


Month


Day


Year


Month


Day


Year
 


Month


Day


Year


Month


Day


Year
 
TOTAL HOURS WORKED

Name of Master Plumber:
Company Name:
Company Address:
Street
City State Zip Code

I certify under penalty of perjury that the applicant named above served as a journey or apprentice plumber under my direction and supervision for the time(s) indicated.
SIGNATURE OF MASTER PLUMBER
Date Signed
Master Plumber Registration Number  State or Jurisdiction