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State Board of Registration for Professional Engineers and Surveyors 50 West Broad Street, Suite 1820

State Board of Registration for Professional Engineers and Surveyors

50 West Broad Street, Suite 1820 • Columbus, Ohio 43215-3301

VOICE (614) 466-3651

EMAIL pes.board@pes.ohio.gov

FAX (614) 728-3059

U.S. TOLL FREE (877) 644-6364

WEB http://ohiopeps.org

Application for Registration

as a Professional Engineer or Professional Surveyor or for certification as an Engineer Intern or Surveyor Intern

I,

SIGN WITH YOUR SIGNATURE — DO NOT PRINT YOUR NAME

, hereby apply for registration

in the State of Ohio and submit the following evidence and application fee as required by Ohio law.

• Required personal information, including photograph.

• Required evidence of education, including an official transcript of college credits.

• Required evidence of experience.

• References [see note (b) on page 3].

• Application fee to accompany application. Fees are not refundable per Ohio A.C. 4733-19-01.

NOTE: If you do not appear for an examination for which you have been approved, you will be charged an additional

This application is for professional registration in the State of Ohio by:

Examination $25.00 application fee Choose only one Engineering Fundamentals (FE) Principles and Practice (PE)

Examination $25.00 application fee

Choose only one Engineering

Fundamentals (FE)$25.00 application fee Choose only one Engineering Principles and Practice (PE) Surveying Fundamentals (FS)

Principles and Practice (PE)application fee Choose only one Engineering Fundamentals (FE) Surveying Fundamentals (FS) Principles and Practice (PS)

Surveying

Fundamentals (FS)fee Choose only one Engineering Fundamentals (FE) Principles and Practice (PE) Surveying Principles and Practice (PS)

Principles and Practice (PS)application fee Choose only one Engineering Fundamentals (FE) Principles and Practice (PE) Surveying Fundamentals (FS)

Comity Application fees below Choose only one Professional Engineer $415.00 application fee PE DISCIPLINE Professional

Comity Application fees below

Choose only one

Professional Engineer $415.00 application fee application fee

PE DISCIPLINE

only one Professional Engineer $415.00 application fee PE DISCIPLINE Professional Surveyor $455.00 application fee

Professional Surveyor $455.00 application fee application fee

Your name as it is to appear officially on your Ohio registration certificate

Your photograph REQUIRED

Passport or passport-style photograph is preferred.

What is required is a recognizable photograph with your face not less than ¾” wide.

Photograph must be a permanent print. Photocopies are not acceptable and will delay your application process.

Social security number

Mailing address line 1

Birth date

Mailing address line 2 (Only if necessary)

Telephone

City

State Province

ZIP Postal Code

Ohio county Country

Email address

Notice Statement. Ohio’s State Board of Registration for Professional Engineers and Surveyors is requesting disclosure of information that is necessary to accomplish our statutory purposes as outlined under Ohio R.C. Chapter 4733. Disclosure of this information is required. Failure to provide any required information may result in this application not being processed.

Engineering information

Have you taken and passed theNO

NO

State

Date taken

Certificate number

Fundamentals of Engineering examination? examination?

YES

Have you taken and passed theNO

NO

State

Date taken

Certificate number

Principles and Practice of Engineering examination? examination?

YES

Are you now registered or have you ever been registered as aNO YES

NO

YESAre you now registered or have you ever been registered as a NO

Professional Engineer in Ohio or in another US state or territory? Registration secured by (written examination, comity, other) Describe:

secured by (written examination, comity, other) Describe: Where granted Certificate number Date granted

Where granted

Certificate number

Date granted

Expiration date

Surveying information

Have you taken and passed theNO

NO

State

Date taken

Certificate number

Fundamentals of Surveying examination? examination?

YES

Have you taken and passed theNO

NO

State

Date taken

Certificate number

Principles and Practice of Surveying examination? examination?

YES

Are you now registered or have you ever been registered as aNO YES

NO

YESAre you now registered or have you ever been registered as a NO

Professional Surveyor in Ohio or in another US state or terri- tory? Registration secured by (written examination, comity, other) Describe:

secured by (written examination, comity, other) Describe: Where granted Certificate number Date granted

Where granted

Certificate number

Date granted

Expiration date

Disciplinary actions

FELONY, MORAL TURPITUDE Have you ever been convicted of; found guilty of, pled guilty to or received treatment in lieu of conviction for; a felony or any offense involving moral turpitude in Ohio or another U.S. state or jurisdiction?

If yes, provide a written statement — signed and dated — explaining the incident(s) and attach the

statement and any supporting documentation to this application. Documentation should include, but is not limited to, court and police records. LICENSE, REGISTRATION Have you ever had a disciplinary action against a professional or vocational license, or registration, or had an application for the same denied in Ohio or another U.S. state or jurisdiction?

If yes, provide a written statement — signed and dated — explaining the incident(s) and attach the statement and any supporting documentation to this application.

Formal education beyond high school

Credit claimed below must be supported by an official transcript from the institution. An application filed without a tran- script cannot be approved until the transcript is received.

Name of institution

until the transcript is received. Name of institution NO YES NO YES Years attended Graduation date

NO

until the transcript is received. Name of institution NO YES NO YES Years attended Graduation date

YES

until the transcript is received. Name of institution NO YES NO YES Years attended Graduation date

NO

the transcript is received. Name of institution NO YES NO YES Years attended Graduation date Degree

YES

Years attended

Graduation date

Degree received

NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience
NO YES NO YES Years attended Graduation date Degree received BOARD USE ONLY Education   Experience

BOARD USE ONLY

Education

 

Experience

 

Additional experience

 

TOTAL

has been the nature and extent of your experience? Use the blank space below when answering. Any additional information pertaining to experience should

Have your supervisor fill out the information below for each employment. If the supervisor is unavailable or unwilling to provide the information, attach a letter explaining the details.

REG. STATE

REG. STATE

REG. STATE

REG. STATE

DATE

DATE

DATE

DATE

PE/PS REG. NO.

PE/PS REG. NO.

PE/PS REG. NO.

PE/PS REG. NO.

EMAIL Optional

EMAIL Optional

EMAIL Optional

EMAIL Optional

SIGNATURE

SIGNATURE

SIGNATURE

SIGNATURE

PHONE

PHONE

PHONE

PHONE

NAME

NAME

NAME

NAME

Mo.

months

Time

Years

and

Yr.

Experience other than college education must be listed. References need not be filled out when applying for the fundamentals’ examinations. Applicants seeking surveying registration must show type and length of property surveying experience.

Title of your position, name and location of employer, character of each employment, degree of responsibility Explain your engineering or surveying experience in sufficient detail to indicate degree of responsibilities and work performed. [See note (c)]

APPLICANT’S PERCENTAGE OF TIME SURVEYING:

APPLICANT’S PERCENTAGE OF TIME SURVEYING:

APPLICANT’S PERCENTAGE OF TIME SURVEYING:

APPLICANT’S PERCENTAGE OF TIME SURVEYING:

be furnished on U.S. letter size plain paper. Date and sign all additional experience pages.

APPLICANT’S PERCENTAGE OF TIME ENGINEERING:

APPLICANT’S PERCENTAGE OF TIME ENGINEERING:

APPLICANT’S PERCENTAGE OF TIME ENGINEERING:

APPLICANT’S PERCENTAGE OF TIME ENGINEERING:

Yr.

To

Mo.

Experience

Dates

Yr.

From

Notes

Mo.

What

(b)

(a)

(c)

4

3

2

1

References REQUIRED UNLESS APPLYING FOR FUNDAMENTALS EXAMINATION

List 5 persons, at least 3 of whom are registered engineers or surveyors, from whom the Board may request information in regard to your character, experience and professional ability. Do not name your relatives or members of this Board.

1

2

3

4

5

Name

Business relationship to applicant

Address

Occupation

Name

Business relationship to applicant

Address

Occupation

Name

Business relationship to applicant

Address

Occupation

Name

Business relationship to applicant

Address

Occupation

Name

Business relationship to applicant

Address

Occupation

Additional information for applicants

It is unlawful for a Professional Engineer or Professional Surveyor in Ohio to engage in or advertise for any work which comes under the provisions of law governing the practice of Professional Engineers and Professional Surveyors unless holding a certificate of registration and current renewal card issued by the Board. Carefully read Ohio R.C. Sections 4733.11 and 4733.19 and determine your situation before making application. Applicants must meet all education and experience qualifications 90 days prior to an examination date pursuant to Ohio A.C. 4733-9-01.

Affidavit TO BE MADE BEFORE A NOTARY PUBLIC OR OTHER OFFICIAL QUALIFIED BY LAW TO ADMINISTER OATHS

State of

 

I,

, being duly sworn,

or affirmed, say that the statements made in this application are true to the best of my knowledge and belief.

APPLICANT SIGNATURE

Subscribed and sworn, or affirmed, to me

this

Witness my hand and seal hereon.

day of

,

.

NOTARY PUBLIC SIGNATURE

My commission expires

NOTARY SEAL
NOTARY
SEAL