MARYLAND DEPARTMENT OF THE ENVIRONMENT
P.O. Box 2057
Baltimore Maryland 21203-2057
(800) 633-6101 Ext 3597
(410) 537-3597
STATE BOARD OF WELL DRILLERS
(410) 537-3168 (FAX)
APPLICATION FOR LICENSE REINSTATEMENT
PLEASE TYPE/PRINT ALL INFORMATION
LICENSE NUMBER: ________________
Applicant's ________________________________________________________________________________
(First Name)
(Middle Name/Initial)
(Last Name)
Mailing Address: ___________________________________________________________________________
(Street/R.F.D.)
Street Address: _____________________________________________________________________________
(If different from above)
__________________________________________________________________________________________
(City)
(County)
(State)
(Zip Code)
******************************************************************************************
Please answer "yes" or "no" to all questions asked below and attach a written explanation for any "yes" answer.
Answering "yes" to a question will not necessarily cause the Board to reject your application.
Since your last license renewal:
_____ 1.
Have you been disciplined or found in violation by a licensing or disciplinary authority of any
state or county, or been convicted or disciplined by a court of any state or county, for an act that
would be grounds for disciplinary action under COMAR 26.05.04.01?
_____ 2.
Are there any outstanding complaints, investigations or charges pending against you in any state,
by any licensing or disciplinary authority related to the practice of well drilling?
_____ 3.
Have you been convicted of, or pled guilty or nolo contendere to a drug-related felony
committed on or after January 1, 1991 or a crime involving moral turpitude (whether or not any
appeal or other proceeding is pending to the conviction or plea set aside)?
_____ 4.
Have the conditions of your employment been affected by any voluntary or involuntary
termination of employment, suspension, or probation for any reason related to your practice of
well drilling?
_____ 5.
Has a claim been brought, settled, or awarded against you for damages related to your practice of
well drilling?
_____ 6.
Have you been disciplined by or found by any court, regulatory, licensing, or disciplinary
authority to be professionally incompetent?
_____ 7.
Have you violated any law, rule or regulation that applies to practicing well drilling after your
license expired?
AOBJ: 5364
MDE/WMA/BWD/RES
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Revision Date (11/04)
Recycled Paper
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