Certified Interior Designer - Original Certification, Initial Application

Full Name:

(First)

(MI)

(Last)

	I have a United States mailing address
	Address:
	City, State Zip:	, -
	County:
	I have a mailing address outside the United States
	Address:

Social Security
Number:

Date of Birth:

- - (MM-DD-YYYY)

Place of Birth:

	I was born in the United States City and State: ,
	I was born outside the United States City and Country:

Daytime Phone
Number:

- -

Personal E-mail address:

Business E-mail address:

(Optional)

You may use the same email address in both fields presently designated for �Business Email Address� and �Personal Email Address�. However, please note that your business address may be released upon the request from a third party. Your personal email address will only be used for the purposes of communications from LABOR. In addition, if you wish to omit your business email address from the lists of licensees that LABOR makes available to third parties, you must notify us in writing or you can opt-out by leaving your business email address blank. You may send your Opt-out notice to dlopl-labor@maryland.gov

	Yes	No
Have you previously applied for certification in the state of Maryland?
If "Yes", give date of application: / /

Have you ever:

1.	Been convicted of a felony or misdemeanor in any State or Federal Court?	Yes	No
2.	Had this type of license, certificate, registration, or permit denied, suspended, or revoked by Maryland or any other jurisdiction?	Yes	No

I have Workers Compensation Coverage Policy/Binder No.

Issued by the

I am not an employer required to provide employee coverage under the Workers Compensation Law.

Certification

By pressing "Submit" below:

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 Labor 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 or have provided for payment in a manner satisfactory to the unit responsible for collection.

In accordance with Executive Order 01.901.1983-18, the Department of Labor is required to advise you as follows regarding the collecting of personal information: Personal information requested by the licensing agency of the Department is necessary in determining your eligibility for licensure. Such personal information is also intended for use as an additional means of verifying the licensee�s identity or 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/her 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 Public Information Act. Personal information is not routinely shared with state, federal or local government agencies.

I affirm that I have carefully read the laws and regulations set forth in Title 8, Business Occupations and Professions Article, Annotated Code of Maryland, and the Code of Maryland Regulations, Title 09, Subtitle 18. I further affirm that I understand and accept my responsibilities under such laws and regulations.

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