Department of Budget and Management

***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.***

Are you a current employee of the Maryland Department of Labor?

Please describe your experience in a public/or private agency rendering and/or determining eligibility for a Human Service Program, or an insurance claims processing and fraud investigations program. Include employer and dates. If none, indicate N/A.

Please describe your knowledge of the BEACON system. Include employer and dates. If none, indicate N/A.

Please describe your knowledge of Maryland Unemployment Insurance laws. Include employer and dates. If none, indicate N/A.

Please describe your Customer Service experience. Include employer and dates. If none, indicate N/A.

Carefully read this authorization to release information about you and check the yes or no box to acknowledge and grant permission for these terms.

I Authorize and give my consent for full and complete disclosure of all records, reports, and information concerning myself to the Maryland Department of Labor or any of Labor’s duly authorized agent(s), whether the said records are private or public, and including those that may be deemed to be of a privileged or confidential nature. The intention of this authorization is to authorize the disclosure of information which will be utilized for reviewing my suitability for qualifications for employment with the Maryland Department of Labor.

I Authorize the release of information to the Maryland Department of Labor or any of Labor’s duly authorized agent(s), relating to my activities from individuals, schools, residential management agents, employers, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, and employment history. I authorize the individual(s) receiving this information to use it for the determination of suitability or eligibility for employment with the Maryland Department of Labor.

I Authorize custodians of such records and other sources of information pertaining to me to release such information upon request to the Maryland Department of Labor or any of Labor’s duly authorized agent(s) regardless of any previous agreement to the contrary.

I understand and acknowledge that prior to my being offered employment by the Maryland Department of Labor, my name will be checked against files maintained by the Maryland Department of Labor, Division of Unemployment Insurance (Labor/DUI) to determine whether I owe any monies to Labor/DUI as a result of an unemployment insurance overpayment. I acknowledge that an unpaid debt may have an impact on whether or not I am offered employment.

I Understand information released by records custodians and sources of information is for official use by the Maryland Department of Labor only for the purposes of determining my suitability and qualifications for employment with Labor and may be disclosed by Labor only as authorized by law.

Photocopies of this authorization that show my signature are valid. This authorization is valid for five (5) years from the date signed or upon the termination of my employment with the Maryland Department of Labor.

'Personnel employed in this classification will have access to federal tax information and must undergo a state and FBI criminal background check as a condition of employment'

Please check yes or no, acknowledging permission of these terms.

7. Full Name:

   Other names used:

8. Date of Birth:
9. Full Social Security Number:

10.Date signed (mm/dd/yyyy):