Form MDE/ARMA/PER.038 "Payment Transmittal - General License" - Maryland

What Is Form MDE/ARMA/PER.038?

This is a legal form that was released by the Maryland Department of the Environment - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 27, 2017;
  • The latest edition provided by the Maryland Department of the Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MDE/ARMA/PER.038 by clicking the link below or browse more documents and templates provided by the Maryland Department of the Environment.

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Download Form MDE/ARMA/PER.038 "Payment Transmittal - General License" - Maryland

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MARYLAND DEPARTMENT OF THE ENVIRONMENT
● Baltimore, Maryland 21230
1800 Washington Boulevard
(410) 537-3000 ● 1-800-633-6101 ● www.mde.maryland.gov
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
RADIOLOGICAL HEALTH PROGRAM
PAYMENT TRANSMITTAL – GENERAL LICENSE
Payer:
Address:
Telephone No.:
E-mail address:
Authorized Contact:
Description: Initial Fee for Possession and Use of General Licensed Radioactive Material
Source(s)
Date Form Completed:____________________
Fee: See current fee schedule at
http://mde.maryland.gov/programs/Air/RadiologicalHealth/Documents/w
ww.mde.state.md.us/assets/document/air/RAM_FEES.pdf
PLEASE: Make your check payable to the:
Maryland Department of the Environment/Radiation Control Fund
IMPORTANT: Mail check with this transmittal form to:
Maryland Department of the Environment
P. O. Box 2198
Baltimore, Maryland 21203-2198
WE MUST HAVE THIS TRANSMITTAL FORM IN
ORDER TO APPLY YOUR FEE TO THE PROPER ACCOUNT
________________________
FOR MDE USE ONLY
PCA:
13701
R*STARS INSTRUCTIONS:
Agency:
U00
Supply CUR.DOC. number on copy.
Object:
5684
Suffix:
707
Transaction Code:
410
___________________________________
Privacy Act Notice: This Notice is provided pursuant to the Federal Privacy Act of 1974, 5 U.S.C. § 552a. Disclosure of your
Social Security or Federal Tax Identification on this form is mandatory pursuant to the provisions of § 1-203 (2003) of
Environment Article, Annotated Code of Maryland, which requires MDE to verify that an applicant for a permit or license has
paid all undisputed taxes and unemployment insurance. Social Security and Federal Tax Identification Nos. will not be used for
any purposes other than those described in this Notice.
Please insert your Federal Tax I.D. Number
or your Social Security Number:
Form Number MDE/ARMA/PER.038
Page 1 of 1
Revision Date 9/27/17
Recycled Paper
TTY Users 1-800-735-2258
MARYLAND DEPARTMENT OF THE ENVIRONMENT
● Baltimore, Maryland 21230
1800 Washington Boulevard
(410) 537-3000 ● 1-800-633-6101 ● www.mde.maryland.gov
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
RADIOLOGICAL HEALTH PROGRAM
PAYMENT TRANSMITTAL – GENERAL LICENSE
Payer:
Address:
Telephone No.:
E-mail address:
Authorized Contact:
Description: Initial Fee for Possession and Use of General Licensed Radioactive Material
Source(s)
Date Form Completed:____________________
Fee: See current fee schedule at
http://mde.maryland.gov/programs/Air/RadiologicalHealth/Documents/w
ww.mde.state.md.us/assets/document/air/RAM_FEES.pdf
PLEASE: Make your check payable to the:
Maryland Department of the Environment/Radiation Control Fund
IMPORTANT: Mail check with this transmittal form to:
Maryland Department of the Environment
P. O. Box 2198
Baltimore, Maryland 21203-2198
WE MUST HAVE THIS TRANSMITTAL FORM IN
ORDER TO APPLY YOUR FEE TO THE PROPER ACCOUNT
________________________
FOR MDE USE ONLY
PCA:
13701
R*STARS INSTRUCTIONS:
Agency:
U00
Supply CUR.DOC. number on copy.
Object:
5684
Suffix:
707
Transaction Code:
410
___________________________________
Privacy Act Notice: This Notice is provided pursuant to the Federal Privacy Act of 1974, 5 U.S.C. § 552a. Disclosure of your
Social Security or Federal Tax Identification on this form is mandatory pursuant to the provisions of § 1-203 (2003) of
Environment Article, Annotated Code of Maryland, which requires MDE to verify that an applicant for a permit or license has
paid all undisputed taxes and unemployment insurance. Social Security and Federal Tax Identification Nos. will not be used for
any purposes other than those described in this Notice.
Please insert your Federal Tax I.D. Number
or your Social Security Number:
Form Number MDE/ARMA/PER.038
Page 1 of 1
Revision Date 9/27/17
Recycled Paper
TTY Users 1-800-735-2258