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MARYLAND STATE DEPARTMENT OF EDUCATION
MD. CODE, EDUC. §6-113.2 APPLICANT R EPORT
Pursuant to Md. Code, Educ. 6-113.2, I am reporting an applicant who may have
provided false information or failed to disclose information related to his or her employment
background.
Name of Applicant:
Address: _____________________________________________________________________
Phone: _________________________________Fax: ________________________________
Email:________________________________________________________________________
Is this individual certified in Maryland? Yes __________No ___________
Please include/attach any supporting documentation or other information relevant to this report.
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.
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