If you answered NO, additional documentation from the Workers’ Compensation Commission must accompany this application (refer to the instruction guide for details). Do you have unemployment insurance? Yes No 5. QUALITY ASSURANCE (QA) PLAN DATE OF INITIAL OR MOST RECENT QA PLAN SUBMISSION DATE OF MOST RECENT QA PLAN APPROVAL (as applicable) IF THE APPROVAL DATE IS GREATER THAN ONE YEAR AGO: REASON FOR THE DELAY PLAN FOR SUBMITTING QA PLAN & ANNUAL REPORT FOR APPROVAL 6. LICENSED SITE LOCATIONS NUMBER OF LICENSED SITE PROPOSED OR LICENSED IS A LIST OF ALL THE LICENSED SITE LOCATIONS ATTACHED Yes No LOCATIONS TO THIS APPLICATION? Attach the of Licensed Site Locations” form available on the OHCQ website at “List 7. EQUAL OPPORTUNITY (VOLUNTARY) (CONSIDER MOVING TO END OF APPLICATION) To further its commitment to equal opportunity, the State of Maryland requests licensees provide the following voluntary information. This information will be used for statistical purposes only by authorized personnel. 1. Is the (applicant) agency certified through the Maryland Department of Transportation (MDOT) as a Minority Business Enterprise (MBE) or Disadvantaged Business Enterprise (DBE)? No Yes 2. Is the (applicant) agency a minority or operated business (at least 51% owned/operated)? No Yes (please complete the following MINORITY CLASSIFICATION NAME OF GOVERNING BODY MEMBER (AFRICAN AMERICAN; HISPANIC; NATIVE AMERICAN; DATE ELECTED OR OR OFFICER OF THE CORPORATION MINORITY? ALASKAN NATIVE; ASIAN AMERICAN; FEMALE) APPOINTED TO POSITION Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 8. OF DIRECTORS MEMBER INFORMATION (Please submit an attachment for any additional members) BOARD MEMBER #1 - MEMBER TYPE: DATE TERM VOTING STAFF COMMUNITY FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER EMAIL ADDRESS: BOARD MEMBER #2 - MEMBER TYPE: DATE TERM VOTING STAFF COMMUNITY FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER EMAIL ADDRESS: BOARD MEMBER #3 - MEMBER TYPE: DATE TERM VOTING STAFF COMMUNITY FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER ADDRESS: BOARD MEMBER #4 - MEMBER TYPE: DATE TERM VOTING STAFF COMMUNITY FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER
If you answered NO, additional documentation from the Workers’ Compensation Commission must accompany this application (refer to the instruction guide for details). Do you have unemployment insurance? Yes No 5. QUALITY ASSURANCE (QA) PLAN DATE OF INITIAL OR MOST RECENT QA PLAN SUBMISSION DATE OF MOST RECENT QA PLAN APPROVAL (as applicable) IF THE APPROVAL DATE IS GREATER THAN ONE YEAR AGO: REASON FOR THE DELAY PLAN FOR SUBMITTING QA PLAN & ANNUAL REPORT FOR APPROVAL 6. LICENSED SITE LOCATIONS NUMBER OF LICENSED SITE PROPOSED OR LICENSED LOCATIONS IS A LIST OF ALL THE LICENSED SITE LOCATIONS ATTACHED TO THIS APPLICATION? Yes No Attach the “List of Licensed Site Locations” form available on the OHCQ website at 7. EQUAL OPPORTUNITY (VOLUNTARY) (CONSIDER MOVING TO END OF APPLICATION) To further its commitment to equal opportunity, the State of Maryland requests licensees provide the following voluntary information. This information will be used for statistical purposes only by authorized personnel. 1. Is the (applicant) agency certified through the Maryland Department of Transportation (MDOT) as a Minority Business Enterprise (MBE) or Disadvantaged Business Enterprise (DBE)? No Yes 2. Is the (applicant) agency a minority or operated business (at least 51% owned/operated)? No Yes (please complete the following NAME OF GOVERNING BODY MEMBER OR OFFICER OF THE CORPORATION MINORITY? MINORITY CLASSIFICATION (AFRICAN AMERICAN; HISPANIC; NATIVE AMERICAN; ALASKAN NATIVE; ASIAN AMERICAN; FEMALE) DATE ELECTED OR APPOINTED TO POSITION Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 8. OF DIRECTORS MEMBER INFORMATION (Please submit an attachment for any additional members) BOARD MEMBER #1 - MEMBER TYPE: VOTING STAFF COMMUNITY DATE TERM FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER EMAIL ADDRESS: BOARD MEMBER #2 - MEMBER TYPE: VOTING STAFF COMMUNITY DATE TERM FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER EMAIL ADDRESS: BOARD MEMBER #3 - MEMBER TYPE: VOTING STAFF COMMUNITY DATE TERM FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER ADDRESS: BOARD MEMBER #4 - MEMBER TYPE: VOTING STAFF COMMUNITY DATE TERM FIRST NAME, MIDDLE INITIAL LAST NAME BOARD POSITION STARTS ENDS ADDRESS (NUMBER, STREET) CITY STATE ZIP PHONE NUMBER
DD%20Application%20for%20Licensure.4.21.14%20(1).docx