State Board of Registration for Professional Engineers and Surveyors

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

VOICE (614) 466-3651 FAX (614) 728-3059 U.S. TOLL FREE (877) 644-6364
EMAIL pes.board@pes.ohio.gov 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, , hereby apply for registration
SIGN WITH YOUR SIGNATURE — DO NOT PRINT YOUR NAME

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: Your photograph REQUIRED
Examination Comity
$25.00 application fee Application fees below
Passport or passport-style
Choose only one Choose only one photograph is preferred.
Engineering Professional Engineer
What is required is a
Fundamentals (FE) $415.00 application fee recognizable photograph with your
Principles and Practice (PE) PE DISCIPLINE face not less than
¾” wide.
Surveying
Fundamentals (FS) Professional Surveyor Photograph must be a
permanent print. Photocopies are
Principles and Practice (PS) $455.00 application fee not acceptable and will delay your
application process.

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

ENG 1011 (Rev. 07/2007) Page 1 of 4

Engineering information
NO Have you taken and passed the State Date taken Certificate number
YES Fundamentals of Engineering examination?

NO Have you taken and passed the State Date taken Certificate number
YES Principles and Practice of Engineering examination?

NO Are you now registered or have you ever been registered as a Where granted Certificate number
YES Professional Engineer in Ohio or in another US state or
territory?
Registration secured by (written examination, comity, other) Date granted Expiration date
Describe:

Surveying information
NO Have you taken and passed the State Date taken Certificate number
YES Fundamentals of Surveying examination?

NO Have you taken and passed the State Date taken Certificate number
YES Principles and Practice of Surveying examination?

NO Are you now registered or have you ever been registered as a Where granted Certificate number
YES Professional Surveyor in Ohio or in another US state or terri-
tory?
Registration secured by (written examination, comity, other) Date granted Expiration date
Describe:

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?
NO YES 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?
NO YES 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 Years attended Graduation date Degree received

BOARD USE ONLY Education

Experience
Additional experience
TOTAL

ENG 1011 (Rev. 07/2007) Page 2 of 4

 Experience
What has been the nature and extent of your experience? Use the blank space below when answering. Any additional information pertaining to experience should
be furnished on U.S. letter size plain paper. Date and sign all additional experience pages.

Dates Title of your position, name and location of employer, Time Have your supervisor fill out the
character of each employment, degree of responsibility Years information below for each employment. If
and
From To Explain your engineering or surveying experience in sufficient detail months the supervisor is unavailable or unwilling

ENG 1011 (Rev. 07/2007)

to indicate degree of responsibilities and work performed. to provide the information, attach a letter
Mo. Yr. Mo. Yr. [See note (c)] Yr. Mo. explaining the details.
NAME

PHONE

1 EMAIL Optional

SIGNATURE DATE

APPLICANT’S PERCENTAGE OF TIME ENGINEERING: APPLICANT’S PERCENTAGE OF TIME SURVEYING: PE/PS REG. NO. REG. STATE

NAME

PHONE

2 EMAIL Optional

SIGNATURE DATE

APPLICANT’S PERCENTAGE OF TIME ENGINEERING: APPLICANT’S PERCENTAGE OF TIME SURVEYING: PE/PS REG. NO. REG. STATE

NAME

PHONE

3 EMAIL Optional

SIGNATURE DATE

APPLICANT’S PERCENTAGE OF TIME ENGINEERING: APPLICANT’S PERCENTAGE OF TIME SURVEYING: PE/PS REG. NO. REG. STATE

NAME

PHONE

4 EMAIL Optional

SIGNATURE DATE

APPLICANT’S PERCENTAGE OF TIME ENGINEERING: APPLICANT’S PERCENTAGE OF TIME SURVEYING: PE/PS REG. NO. REG. STATE

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

Page 3 of 4
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.
Name Business relationship to applicant
1
Address Occupation

2 Name Business relationship to applicant

Address Occupation

3 Name Business relationship to applicant

Address Occupation

4 Name Business relationship to applicant

Address Occupation

5 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 day of , .
Witness my hand and seal hereon.
NOTARY
NOTARY PUBLIC SIGNATURE
SEAL
My commission expires

ENG 1011 (Rev. 07/2007) Page 4 of 4