STATE OF MARYLAND - Maryland Department of Labor
|ELEVATOR MECHANIC LICENSE |
APPLICANT: INCLUDE COPIES OF W2 FORMS OR OTHER FORMS
EMPLOYMENT VERIFICATION
THIS BLANK FORM MAY BE DUPLICATED AS NEEDED. A copy must be completed for each employer. Only original signed certification will be accepted.
|Applicant’s Full Name: | |
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|Applicant’s Social Security Number: | |
TO BE COMPLETED BY EMPLOYER:
EMPLOYER: This form is being provided to you so that you may provide verification as to the time this applicant has worked as an elevator mechanic.
An ELEVATOR MECHANIC is a person who is engaged in erecting, constructing, wiring, altering, replacing, maintaining, repairing, dismantling, or servicing elevators, dumbwaiters, escalators, and moving walks.
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|Address of Company: | |
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|Dates of employment for the applicant Months/Years): | |
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|Employee’s job classification: | |
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|What are or were the employee’s principal duties: | |
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|List any training or educational programs the employee did. | |
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|Name of employee’s immediate supervisor: | |
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|Job title: | |
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|Other Comments: | |
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|I CERTIFY THAT THE CONTENTS OF THIS DOCUMENT ARE TRUE AS STATED: |
|Name of person completing this form: | |
| |(Please print or type name) |
|Title of person completing this form: | |
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|Telephone number(s) where person can be reached: | |
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|E-Mail address: | |
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|SIGNATURE OF EMPLOYER: | |Date: | |
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STATE OF MARYLAND
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MENT OF LABOR, LICENSING AND REGULATION
ELEVATOR SAFETY REVIEW BOARD
500 N. CALVERT STREET
BALTIMORE, MD 21202
FAX: 410-333-6314
TTY users call Maryland Relay Service
E-Mail: elevator@dllr.state.md.us
FOR OFFICE USE ONLY
Date received: _________________
Approved by: _________________
Date: ________________________
Denied ______________________
Date: ________________________
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