Renewal Application for Electrician License
2425 Reedie Drive, 7th Floor Wheaton, MD 20902 Phone: 311 in Montgomery County or (240) 777-0311
Renewal Application for Electrician License
A. Purpose:
Journeyman
Master Limited
Master
To review our current licensing procedures & fees please visit our website or call 311 (240-777-0311 if outside Montgomery County) for current fee schedule
NOTE: FEES MAY BE SUBJECT TO ANNUAL CHANGES EFFECTIVE JULY 1ST.
B. For Office Use Only
License No.
Issue Date
Expiration Date:
Approved { }
Disapproved { }
Signature
Date
**If license was obtained by reciprocation, you MUST include a copy of the current license from that jurisdiction**
COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION MUST BE SUBMITTED VIA EMAIL TO: DPS.ELECTRICAL-MECHANICAL@
PAYMENT INSTRUCTIONS WILL BE PROVIDED ONCE APPLICATION IS PROCESSED C. Applicant Information: (Applications that are not complete will be returned).
Applicant Name
LICENSE NUMBER _
Address
Home Telephone
City
State
Zip
E-mail Address
In-Active Active
(if active please provide the following information)
Business Name (affiliation)
Business Address
City
State
Zip
Business Phone
Business License No.
D. Licenses and Violations: (Since last renewal). 1. Have you had your Electrical License or Bond suspended or revoked?
{ } Yes
{ } No
2. Are there any electrical code violations now outstanding against electrical permits issued to you?{ } Yes
{ } No
3. Are there any pending law suits or unsatisfied judgements outstanding against you? 4. Have you been convicted of a criminal offense other than a traffic violation?
{ } Yes { } Yes
{ } No { } No
(If YES to any of the above questions, give dates, license #, and details in section below*.)
E. 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 Permitting Services for further investigation.
Applicant Original Signature
Date
Print Name *Additional Information For Section D:
Page 1 of 1 Revised 2/16/2021
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