MARYLAND STATE DEPARTMENT OF EDUCATION
REQUEST FOR INFORMATION ON AN APPLICANT’S CERTIFICATION STATUS
On behalf of _________________________________, I am requesting the certification status of
the following applicant for a position, pursuant to Md. Code, Educ. §6-113.2:
Name of Applicant (include any prior names): ________________________________________
Date of Birth: _______________ Last Four Digits of Social Security Number: ________
Employer Requesting Information: _________________________________________________
Employer Contact Name: _________________________________________________________
Address: _____________________________________________________________________
Phone: ___________________ Email: ______________________________________________
(to be filled out by the Maryland State Department of Education)
The above-listed individual:
1. Holds or has held a Maryland Educator Certificate yes no;
2. Is the Maryland Educator Certificate active? yes no; If yes, complete the following:
Type: _____________________________________ Validity: ___________________________
Area(s):_____________________________________
3. Has had a certificate suspended, revoked, or denied in Maryland for reasons of child abuse or
sexual misconduct yes no
Action taken (suspension, revocation, denial): ___________________________
Date of action:______________________
Cause:________________________________________________________________________
The individual has never held a Maryland Educator Certificate
Name of MSDE Representative
Date
Signature
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