2011 -REACTIVATION FOR RENEWAL FORM 2010-2012 FINAL - dhmh maryland-2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your name and BD LIC. / REG. NO. in the designated fields at the top of the form.
  3. Fill in your current phone number and mailing address, ensuring all information is legible.
  4. Provide your email address for communication purposes, as this is crucial for updates from the Board.
  5. Complete the Workers’ Compensation Insurance section if applicable, including insurance company details and policy number.
  6. Answer all questions in the Professional Competency & Background section with 'YES' or 'NO', providing explanations on a separate sheet for any 'YES' answers.
  7. Attach copies of your CEU certificates and CPR certification as required before submitting the form.
  8. Review all sections to ensure completeness, then sign and date the application at the bottom before submission.

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