STATE OF MARYLAND
Department of Labor, Licensing and Regulation
Secondhand Precious Metal Object Dealers / Pawnbrokers
500 N. Calvert St., Room 304
Baltimore, Maryland 21202-3651
(410) 230-6222 (Baltimore area), or (888) 218-5925 (Toll Free)

Dealers Report of Employee Printable Form

SECTION 1. INSTRUCTIONS FOR APPLICANTS
1. The dealer / pawnbroker and prospective employee must complete this form. All information must be typewritten or clearly printed in ink. Incomplete forms will not be accepted. Mail the completed form to the above address.
2. The dealer / pawnbroker must submit a separate form for each prospective employee who will be employed by the dealer / pawnbroker to buy, sell, or supervise directly the buying or selling of secondhand precious metal objects.
3. As an employee of a dealer who will be engaging in secondhand precious metal object transactions you are required to apply to the Criminal Justice Information System Central Repository (CJIS) for a national and State criminal history records check. You may not engage in precious metal object or pawn transactions until the Department advises your employer that you may do so.

SECTION 2. DEALER'S INFORMATION
Dealer's Name (Last, First, M.I.):
 
Business Name:
 
Business Address: 
City, State, Zip: 
Registration Number:     Social Security No.: 
Bus. Telephone No.:     E-mail Address: 

SECTION 3. EMPLOYEE'S INFORMATION
Employee's Name (Last, First, M.I.):
 
Home Address: 
City, State, Zip: 
County:     Social Security No.: 
Home Telephone No.:     E-mail address: 
Date of Birth:     Place of Birth: 
Driver's License No.:     Driver's License State: 

SECTION 4. ADDITIONAL INSTRUCTIONS AND INFORMATION
You should go to the nearest designated agency to complete both the CJIS Application for Criminal History Record Check (orange form) and the Federal Bureau of Investigation application (blue form). Once your fingerprints have been placed on these two forms, mail both forms and the appropriate fees payable by check or money order (no cash) to:

    CJIS-CENTRAL REPOSITORY
    P.O Box 32708
    Pikesville, MD 21282-2708
The CJIS-Central Repository will send an Acknowledgement receipt of your request for a criminal history records check to the Department of Labor, Licensing and Regulation (DLLR). Once your employer (dealer) has been advised by DLLR of the receipt of your CHRI Request Acknowledgment, you will be eligible to engage in precious metal object and pawn transactions pending DLLR's receipt of the State and FBI Criminal History Report. You may not engage in precious metal object or pawn transactions until DLLR advises your employer that you may do so.

PLEASE NOTE: This Dealer Report of Employee Form will be retained on file with DLLR. After DLLR receives and reviews both the national and State criminal history records reports, your employer will be notified of your eligibility for continued employment pursuant to Section 12-209 Business Regulation Article, Annotated Code of Maryland. The normal processing time for the national and State criminal history records to be received by the Department averages seven weeks.

SECTION 5. IMPORTANT NOTICE
In accordance with Executive Order 01.01.1983-18, the Department of Labor, Licensing and Regulation is required to advise you as follows regarding the collection of personal information:

Personal information requested by the licensing agency of the department is necessary in determining you eligibility for licensure. Such personal information is also intended as an additional means of verifying the licensee's identity to enable the agency to communicate, in a timely manner, with the licensee should the need arise. The licensee has a right to inspect his personal record and to amend or correct the personal data if necessary.

Personal information is generally available for inspection by the public only in accordance with the Maryland Public Information Act.

SECTION 6. QUESTIONS AND CERTIFICATIONS (for prospective employee)
Circle the correct answers:
1. Have you ever been convicted of a felony or misdemeanor in any State or Federal court? Yes No
2. Have you ever had this type of license denied, suspended, or revoked by Maryland or any other State? Yes No
3. Have you been convicted of or received probation before judgement of any drug offense committed after January 1,1991? Yes No

    If you have answered yes to any of the above questions, you must submit the following:

    • A typed letter giving a complete explanation of the incident(s)
    • A true test copy of the applicable court document(s)
    • A copy of the final order in your case(s)

    Please mail these documents to the above address.

    EMPLOYEE'S AFFIDAVIT

    I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. I further authorize the release of any information contained within this application to an authorized representative of the Department of Licensing and Regulation for further investigation. I further certify that I have paid all undisputed taxes and unemployment insurance contributions payable to the Comptroller or the Department of Labor, Licensing and Regulation or have provided for payment in a manner satisfactory to the unit responsible for collection.
    Signature of Applicant    

    Date Signed



    FOR OFFICE USE ONLY
    Date Received:
    Date CJIS Receipt Received:
    Date CJIS Report Received:
    Date FBI Report Received:
    APPROVED BY:
       Date
    DENIED BY:
       Date
    REASON FOR DENIAL: