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* Department OR BOARD:
(If you don't have a specific board name, please select the
Department name that you may be interested in
Press Ctrl key and Click to select more than one name)
Please select a Board or a Department name
Total Character exceeds maxmium (1000) limit!
Selected Board/Department Names:
* Application for:
Please select Application Type!
*First Name:
Please enter Firs Name
Middle Initial:
* Last Name:
Please enter Last Name!
* Date of Birth: (mm/dd/yyyy)
Invalid Date of Birth!
* Race:
Race is not selected!
* Gender:
(Ethnic/gender data is solely to assure diversity in representation)
Gender is not selected!
* Home Address Line 1:
Home Address field is empty!
Home Address Line 2:
* City:
Please enter City!
* State:
Please select State!
* Zip:
Please enter Zip Code!
* Resident County:
Please select County!
MD Legislative District:
MD Congressional District:
Council or Commission District:
* Occupation:
Please fill Occupation field!
* Employer:
Please fill Employer field!
* Work Address Line 1:
Please fill Work Address field!
Work Address Line 2:
* City:
Please fill City field!
* State:
Please select State!
* Zip Code:
Please enter Zip Code!
* County:
Please select County!
Phones:
* (Office): (xxx-xxx-xxxx)
Invalid Phone number!
Please enter Office Phone Number
* (Home): (xxx-xxx-xxxx)
Invalid Phone number!
Please enter Home Phone Number
* (Cell): (xxx-xxx-xxxx)
Invalid Phone number!
Please enter Cell Phone Number
(Fax): (xxx-xxx-xxxx)
Invalid Phone number!
* Email Address:
Email field is empty!
Invalid Email Address!
Sponsoring Organization (If Any):
Maxium characters limit: 500
* Have you ever had a license to practice a profession or trade, whether held in Maryland or another state, revoked or suspended?
Check Yes or No!
Maxium characters limit: 500
Please specify!
* Are you a member, officer or director of any organization, or trade organization?
Check Yes or No!
Specify Organization or Activity:
Maxium characters limit: 500
Please specify!
* Are you a paid lobbyist for any organization?
Check Yes or No!
If so, please specify the organization:
Maxium characters limit: 500
Please specify!
* Do you hold, or have you held in the past, an elected or appointed office within Federal, State or local government, or a political party?
Check Yes or No!
Specify Office:
Please enter Elected Office Name
Specify Date:
(mm/dd/yyyy)
Invalide Elected Date
* Have you filed all Federal and State tax returns that are now due or overdue and are all payments thereupon up to date?
Check Yes or No!
Please specify!
* Have Federal, State or local authorities ever instituted a lien or other collection procedures against you?
Check Yes or No!
Please specify!
* List the names, business addresses, and business telephone numbers of at least 2 individuals who are familiar with your professional qualifications and who have known you for more than the last five years:
Please fill references field
Maxium characters limit: 500
* Please attach a resume that includes information concerning your academic background,
work experience and professional, political and civic organization affiliations.
*
Please upload resume
* ORGANIZATIONAL AFFILIATIONS:
Please enter organizational affiliations!
Maxium characters limit: 500
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