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.

|Name of Company: |      |

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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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