MD-BSWE - 10/26/2023 Page 1 of 6
Maryland Board of Social Work Examiners
4201 Patterson Avenue • Baltimore, Maryland 21215 • (410) 764-4788
APPLICATION FOR RECOGNITION OF OUT-OF-STATE SOCIAL WORK LICENSURE PURSUANT TO THE VETERANS
AUTO AND EDUCATION IMPROVEMENT ACT OF 2022 (PL 117-333) CHECKLIST
INCLUDED
REQUIRED DOCUMENTS
Copy of military orders indicating military service in MD (or if application is for a spouse, provide the
sponsor’s military orders indicating the spouse’s name, or in cases where military orders do not have
the spouse’s name listed, provide a copy of the marriage certificate with the military orders).
☐
State Licensure Affidavit(s) from each State where a license was held, including
Limited/Temporary licensure, verifying that the license is in good standing.
**Primary Source Verification: Defined as verification by the original source of a specific credential to
determine the accuracy of a qualification reported by an individual health care practitioner.
☐
Documentation of legal name change if applicable (i.e., marriage certificate, divorce decree, legal
name change).
MAIL APPLICATION AND SUPPORTING DOCUMENTS TO:
Maryland Board of Social Work Examiners
4201 Patterson Avenue Baltimore, MD 21215
If you have questions, please contact the Director of Certification and
Licensing
Gloria Jean Hammel, LCSW-C
IF YOU PLAN TO PRACTICE SOCIAL WORK IN MARYLAND AFTER YOU OR YOUR SPOUSE’S MARYLAND MILITARY ORDERS
EXPIRE, DO NOT COMPLETE THIS APPLICATION. INSTEAD, COMPLETE THE APPLICATION FOR SOCIAL WORK LICENSURE
BY ENDORSEMENT USING THE ONLINE APPLICATION SYSTEM. THERE IS A FEE ASSOCIATED WITH THIS APPLICATION.
https://mdbnc.health.maryland.gov/bswe/NewApplicant/default.aspx
MD-BSWE - 10/20/2023 Page 2 of 6
Maryland Board of Social Work Examiners
4201 Patterson Avenue
Baltimore, Maryland 21215
(410) 764-4788
APPLICATION FOR RECOGNITION OF OUT-OF-STATE SOCIAL WORK LICENSURE PURSUANT TO THE VETERANS
AUTO AND EDUCATION IMPROVEMENT ACT OF 2022 (PL 117-333)
COMPLETE THIS APPLICATION ONLY IF:
(1) YOU ARE A SOCIAL WORKER WHO IS PRESENTLY A SERVICEMEMBER OR A SOCIAL WORKER WHO HAS A SPOUSE WHO IS A
SERVICEMEMBER;
(2) YOU HAVE A SOCIAL WORK LICENSE IN A STATE OR STATES OTHER THAN MARYLAND THAT ARE IN GOOD STANDING AND
THAT YOU HAVE ACTIVELY USED DURING THE 2 YEARS IMMEDIATELY PRECEDING YOUR MILITARY RELOCATION TO
MARYLAND (3) EITHER YOU OR YOUR SPOUSE ARE UNDER ORDERS TO PROVIDE MILITARY SERVICE IN MARYLAND, AND
(4) YOU OR YOUR SPOUSE SEEK A RECOGNITION TO PRACTICE SOCIAL WORK THAT IS EFFECTIVE ONLY DURING THE
PENDENCY OF YOUR OR YOUR SPOUSE’S MILITARY SERVICE IN MARYLAND. THERE IS NO FEE ASSOCIATED WITH THIS
APPLICATION.
IF YOU PLAN TO PRACTICE SOCIAL WORK IN MARYLAND AFTER YOU OR YOUR SPOUSE’S MARYLAND MILITARY ORDERS
EXPIRE, DO NOT COMPLETE THIS APPLICATION. INSTEAD, COMPLETE THE APPLICATION FOR A SOCIAL WORK LICENSURE
BY ENDORSEMENT USING THE ONLINE APPLICATION SYSTEM. THERE IS A FEE ASSOCIATED WITH THIS APPLICATION.
https://mdbnc.health.maryland.gov/bswe/NewApplicant/default.aspx
Please note the following:
"Servicemember" is defined as a member of the “uniformed services.” “Uniformed services” means (a) the armed forces; (b) the
commissioned corps of the National Oceanic and Atmospheric Administration; and (c) the commissioned corps of the Public Health
Service. "Armed forces" is defined as " Army, Navy, Air Force, Marine Corps, Space Force, and Coast Guard."
"Spouse" is defined as "husband or wife, as the case may be."
“Reside in the State of Maryland” is defined as Maryland being the site of your or your spouse’s duty station. “
Are you a:
Servicemember: ☐Yes ☐No Spouse of a Servicemember: ☐Yes ☐No
SECTION I- INITIAL QUALIFICATIONS for SERVICEMEMBER (Servicemember spouses will answer in the next section)
You must meet the following initial qualifications to obtain a Servicemember Social Work Recognition. If you answer “No” to any of the questions in
SECTION I – Initial Qualifications for SERVICEMEMBER you may not be considered for a Servicemember Social Work Recognition.
Servicemembers only please answer the following questions.
YES NO
☐ ☐ a. Are you presently a “servicemember” as defined above?
YES NO
☐ ☐ b. Do you “reside” (as that word is defined above) in Maryland as a result of military orders?
YES NO
☐ ☐ c. Are all social work licenses that you presently hold in other States in “good standing”?
YES NO
☐ ☐ d. Have you actively used one or more social work licenses during the two years immediately preceding your relocation
to Maryland?
YES NO
☐ ☐ e. Are you recognized as a social worker in any state?
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SECTION II- INITIAL QUALIFICATIONS for SERVICEMEMBER SPOUSE
You must meet the following initial qualifications to obtain a Servicemember Spouse Social Work Recognition. If you answer “No” to any of the
questions in SECTION II– Initial Qualifications FOR SERVICEMEMBER SPOUSE, you may not be considered for a Servicemember Spouse Social Work
Recognition.
Servicemembers spouses only please answer the following questions.
YES NO
☐ ☐ a. Are you presently the spouse of a “servicemember” as those terms are defined on page 2?
YES NO
☐ ☐ b. Do you or your spouse “reside” (as that word is defined on page 2) in Maryland as a result of your spouse’s military orders?
YES NO
☐ ☐ c. Are all social work licenses that you presently hold in other states in “good standing”?
YES NO
☐ ☐ d. Have you actively used one or more social work licenses during the two years immediately preceding your relocation
to Maryland?
YES NO
☐ ☐ e. Are you recognized as a social worker in any other state?
SECTION III – GENERAL INFORMATION
NAME:
First Middle Initial Last
STREET ADDRESS:
TELEPHONE NUMBER:
HOME ( ) WORK ( ) CELL ( )
EMAIL ADDRESS:
SOCIAL SECURITY NO: BIRTHDATE:
Gender Identification: Male Female Other Prefer Not To Answer
Enter Name of the University Attended for your MSW and Graduation Date Below:
(Name of University) (Date Graduation)
Select one or more of the following racial categories:
Are you of Hispanic or Latino Origin? Yes No Prefer not to answer.
(Please circle all applicable; for statistical purposes only)
1 – White
2 – Black or African American
3 – American Indian or Alaska Native
4 – Asian
5 – Native Hawaiian or other Pacific Islander
6 – Other
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Licensure in other states:
Please list other states or jurisdictions in which you hold or have held a social work license. Include license number(s).
Continue on separate page if required
(State)
(License/Registration No.)
(Original License Date)
(Expiration Date)
(State)
(License/Registration No.)
(Original License Date)
(Expiration Date)
(State)
(License/Registration No.)
(Original License Date)
(Expiration Date)
(State)
(License/Registration No.)
(Original License Date)
(Expiration Date)
SECTION IV - CHARACTER AND FITNESS – TO BE ANSWERED BY SERVICEMEMBERS AND THEIR SPOUSES
If you answer “YES” to any question(s) in Section IV – Character and Fitness, attach a separate page with a complete
explanation of each occasion. Each attachment must have your name in print, signature, and date.
YES NO
☐ ☐ a) Is your application for licensure before another State Board at this time?
If yes, provide details:
☐ ☐ b) Has your license to practice in any State ever been subject of an investigation and/or
disciplinary action?
If yes, provide details:
☐ ☐ c) Has your application for a social work license ever been withdrawn or denied for any reason?
If yes, provide details:
☐ ☐ d) Have you ever voluntarily surrendered your license due to violation of state licensing laws?
If yes, provide details:
☐ ☐ e) Has any licensing or disciplinary board of any jurisdiction, including Maryland, or any federal
entity denied your application for licensure, reinstatement, or renewal, or taken any action
against your license, including but not limited to reprimand, suspension, revocation, a fine,
or non-judicial punishment? If you are under a Board Order in a state other than Maryland or
have ever been, you must enclose a certified copy of the Order with this application.
If yes, provide details:
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☐ ☐ f) Have you ever been convicted of a crime?
If yes, provide details:
☐ ☐ g) Have you pled guilty, nolo contendere, had a conviction or receipt of probation before judgment or
other diversionary disposition of any criminal act, excluding minor traffic violations?
If yes, provide details:
☐ ☐ h) Have you pled guilty, nolo contendere, had a conviction, or receipt of probation before
judgment or other diversionary disposition for an alcohol or controlled dangerous substance
offense, including but not limited to driving while under the influence of alcohol or controlled
dangerous substances?
If yes, provide details:
☐ ☐ i) Has the use of drugs and/or alcohol resulted in an impairment of your ability to practice your
profession?
If yes, provide details:
☐ ☐ j) Have you been named as a defendant in a filing or settlement of a malpractice action? If
yes, submit a current copy of your National Practitioner Data Bank report. (You may call 1-
800-767-6732 to obtain information.)
If yes, provide details:
☐ ☐ k) Have you surrendered or allowed your license to lapse while under investigation by any
licensing or disciplinary board of any jurisdiction, including Maryland, or any federal entity?
If yes, provide details:
☐ ☐ l) Has your employment been affected, or have you voluntarily resigned from any
employment, in any setting, or have you been terminated or suspended,
or any
federal entity for any disciplinary reasons or while under investigation for
disciplinary reasons?
If yes, provide details:
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AFFIDAVIT:
Practice of social work without a current recognition of an out-of-state social work license issued by the Maryland Board os
Social Work Examiners is a violation of the Maryland Social Work Act. I affirm that the contents of this document are true
and correct to the best of my knowledge and belief. Failure to provide truthful answers may result in disciplinary action.
I agree that the Maryland Board of Social Work Examiners (the “Board”) may request any information necessary to
process my application for Recognition of Out-of-State Social Work Licensure Pursuant to the Veterans Auto and Education
Improvement Act of 2022 (PL 117-333) from any person or agency, including but not limited to graduate program
directors, individual social workers, government agencies, the National Practitioner Data Bank, and other licensing bodies,
and I agree that any person or agency may release to the Board the information requested. I also agree to sign any
subsequent release for information that may be requested by the Board.
I agree that I will fully cooperate with any request for information or with any investigation related to my practice as a social
worker in the State of Maryland, including the subpoena of documents or records.
During the period in which my application is being processed, I shall inform the Board within 30 days of any change to any
answer I originally gave in this application, any arrest or conviction, any change of address or any action that occurs based
on accusations that would be grounds for disciplinary action under the Annotated Code of Maryland, Health Occupations
Article, § 16-311.
Notice for Mailing List:
The information collected on this application form is collected for the purposes of the Board’s functions under the Annotated Code
of Maryland, Health Occupations Article, Title 19. Failure to provide the information may result in the denial of your application. You
have a right to inspect, amend, and request correction of this information. The Board may permit inspection of this information or
make it available to others only as permitted by federal and State law. Under the Maryland Public Information Act, Annotated Code
of Maryland, General Provisions Article, §4-333, the Board may provide, for a fee, a list of licensees’ names and addresses to
professional associations and other entities. You may request in writing that your name be omitted from such lists.
Applicant Signature Date
