Form Mde/wma/bwd/rea - Application For License Reactivation Page 2
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3I certify that I have received a copy of the Board’s General Regulations - COMAR 26.05.01 through 26.05.04 and that I
have read and understand the provisions of the regulations. I have not committed any act, which would be grounds for
any disciplinary action against me under the regulations. Any exception to this certification is noted on this application.
I also hereby affirm that this application contains no willful misrepresentation or falsification and that the information
given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time
disclose any misrepresentation or falsification, my application may be disapproved, or my license, if already issued, may
be revoked.
_________________________
_____________________________________________
(Date)
(Signature of Applicant)
AFFIDAVIT
State of ___________________________)
)
ss.
County of _________________________)
Subscribed and sworn to before me this _____ day of _______________, 20___.
(Seal)
________________________________________
Notary Public
My Commission Expires ____________________
**************************************************************************************************
Employer’s Certification
I hereby affirm that ______________________________________, who is applying for license reactivation
(Name of Applicant)
is and has been employed by _______________________________________ since _____________________.
(Company)
(Date)
________________________________
________________________________
(Name of Company Official, Printed)
(Title)
_________________________________
(Signature of Official)
________________________________
(_______) ________ - ____________
(Date)
(Business Telephone Number)
AOBJ: 5364
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MDE/WMA/BWD/REA
Revision Date (11/04)
Recycled Paper
TTY Users 1-800-735-2258
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