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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