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MARYLAND STATE DEPARTMENT OF EDUCATION
MD. CODE, EDUC. §6-113.2 EMPLOYER REPORT
Pursuant to Md. Code, Educ. 6-113.2, I am reporting a current or former employer that has not
responded to our request for information on the employment background of an applicant for a
position, or has declined to provide information for a reason other than it is against the laws of
the state in which the employer is located, or disclosure is restricted by the terms of a contract
entered into before June 30, 2019.
Name of Current/Former Employer: ________________________________________________
Address: _____________________________________________________________________
Phone: _________________________________Fax: ________________________________
Email:________________________________________________________________________
We have made the following attempts to contact the above-named employer (please list all
attempted contacts, dates, means used to contact the current or former employer, and any
response):
Please include/attach any supporting documentation or other information relevant to this report
to include a copy of the Employee History Review Form sent.
Individual Making Report: ________________________________________________________
Title: _________________________________________________________________________
Employer: _____________________________________________________________________
Address: ______________________________________________________________________
Phone: ______________________________ Email: ___________________________________
Please email this form and applicable supporting documentation to
61132submissions.msde@maryland.gov or fax to 410-333-8963.
