STATE OF MARYLAND



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REGISTRATION FOR OIL AND GAS LAND PROFESSIONALS

|APPLICANT INFORMATION |

|Last Name |First and Middle Name |Title |Social Security No. |License No./State Issued |

|      |      |      |      | |

| | | | | |

| | | |Date of Birth | |

| | | | | |

| | | |              | |

| | | |YYYY-MM-DD | |

| | | | |

|Residence Address (street address, city, state, zip code) |Home |Fax |Email Address |

|      |(      )      -      |(      )      -      |      @     .      |

| |Cell or Other | | |

| |(      )      -      | | |

|APPLICANT LICENSE & FEE |

| |

|Upon program approval, you must submit a $50 non-refundable registration fee. Do not send your payment with this application. |

| |

|BACKGROUND AS LAND PROFESSIONALS |

| |

|List any professional designations or credentials held relating to your activities as a Land Professionals that you intend to advertise, if any:       |

| |

|Please provide copies of the professional designations or credentials with your applications. |

|CERTIFICATION |

| |

|I hereby certify, under penalty, that all 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 of the State of Maryland or have provided for payment |

|in a manner satisfactory to the unit responsible for collection. |

| |

| |

| | |

|_________________________________________________________ |__________________________________ |

|Applicant Signature |Date |

-----------------------

STATE OF MARYLAND

DEPARTMENT OF LABOR

DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING

500 N. CALVERT STREET

BALTIMORE, MD 21202

(410) 230-6264 FAX: 410-333-6314

E-MAIL: dlopl-dllr@

FOR OFFICE USE ONLY

Date received: ________________

Approved: ____________________

Denied: _____________________

Reason: ______________________

Reg. No. _____________________

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