Maryland State Police Forms

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					STA TE OF MA RYLAND                                                                                                                                 OFFICE US E ONLY
MARYLAND DEPA RTME NT OF S TA TE POLICE                                                                                                        DATE REQUES T RECEIVED BY MSP

RAILROAD COMPANY NAME                                                                      TRADING/OPERATING AS                                DATE REQUEST REVIEWED BY MSP

CORPORATE ADDRESS (Street, City, State, Zip)                                                                                                   DATE REQUES T APPROVED BY MSP

                                                                  APPLICANTS INFORMATION
1. Applicant (Last, First, MI)                                                                                                             2. Social Security Number
3. Address (Number) (Street) (Apt#)                                   (City )                                      (State)                                   (Zip Code + Four Digit)

4. Date of Birth (M/D/YYY Y )                                                   5. Place of Birth (City & State)

6. Driv er’s License Number                                                     7. State                                                  8. Expiration Date (M/D/YYY Y )

9. Phy sical Description (Height)        10. Physical Description (Weight)             11. Physical Description (Ey e Color)              12. Physical Description (Hair Color)

                                                CHI EF RAILROAD POLI CE OFFICER’S INFORMATI ON
13. Chief Railroad Police Off icer (Last, First, MI)                                                                                       14. Telepho ne Number
15. Business Address (Number) (Street) (Apt#)                         (City )                                      (State)                                   (Zip Code + Four Digit)

16. Railroad Police Commission Certification Number                             17. State                                                 18. Expiration Date (M/D/YY YY )

                                                 QUALIFICATIONS AND APPLI CABILITY STATEMENT

Is the State of Maryland the aforementioned applicant’s state of legal residence or state of primary employment?                                                             Y es   No

Is the company seeking to employ the aforementioned applicant located wholly or partly in the State of Maryland?                                                             Y es   No

Does the applicant meet all educational and training requirements required by the Maryland Police Training                                                                   Y es   No
Is the applicant being employed to protect property, patrons, passengers, tenants, employees, equipment and services:                                                        Y es   No
and preserve peace and order on railroad premises, easements, appurtenant property, trains, cars, and other vehicles?
Was the applicant 21 years of age when the State of Maryland Railroad Police Commission application was submitted?                                                           Y es   No

If you answered NO to ANY of the above questions, the Maryland State Police cannot continue the processing of this applicant as the
minimum criteria required by statute has not been met.

                                 ACKNOWLEDGEMNENT (must be accompanied by notarized signature)

I, as the Chief Railroad Police Officer for the Railroad Company listed above, hereby attest that all information recorded on this
Certification of Application for a State of Maryland Railroad Police Commission is true, accurate, complete and that the applicant
meets all State and Federal requirements for a State of Maryland Railroad Police Commission. I further understand that the
submission of this form and that the application for this candidate does not automatically imply commiss ioning and the Maryland State
Police reserves the right to request and audit any or all documentation and information referenced or submitted as part of the
application at any time.

I HEREBY CERTIFY that on this ____ of _________, 20____ before me, a Notary Public for said State and County, personally
appeared the affiant and made oath in due form of law that the matters and facts hereinabove set forth are true to the best of his
knowledge, information and belief.
PRINTED NAME OF CHIEF RAILROAD POLICE OFFICER                                   SIGNATURE OF CHIEF R AILROAD POLICE OFFIC ER                                     Date

                                                                                Notary Public:
                                                                                State of:                                    County of:
Subscribed and sworn to before me:                                                                                                                                      Seal
                                                                                This                 Day of                                    20
                                                                                My Commission Expires:

MAIL WITH APPLICATION TO: The Maryland State Police Licensing Division, 1111 Reisterstown Road, Pikesville, MD 21208
MDSP Form 29-200 (10/09)                                        ATTACH THIS FORM TO ORIGINAL APPLICATION

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