READ ALL INSTRUCTIONSTHE FOR EACH QUESTION BEFORE ANSWERING. The application may NOT be submitted electronically or by fax, as we do require your original signature
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OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS
Licensure, examination verification request
2013-OH
TO BE COMPLETED BY APPLICANT
U.S. SSN
NAME
Last 4 ONLY
REQUESTED BY:
REQUESTED FROM >> U.S. BOARD
STATE OF OHIO ENGINEERS AND SURVEYORS BOARD 50 W BROAD ST STE 1820 COLUMBUS OH 43215-5905
BIRTH DATE >> MM/DD/YYYY
APPLICANT ADDRESS
REQUESTING VERIFICATION FOR:
E.I.
S.I.
P.E.
P.S.
TO BE COMPLETED BY ‘REQUESTED FROM’ U.S. BOARD Applicant is certified or registered as: CERTIFICATE NUMBER
ISSUED >> MM/DD/YYYY
VALID UNTIL >> MM/DD/YYYY
E.I. Engineer Intern ............. S.I. Surveyor Intern ............. P.E. Professional Engineer ... P.S. Professional Surveyor ...
Licensure method Applicant is certified or registered by: HOURS RESULTS
Written examination
NCEES YES NO
EXAM DATE >> MM/DD/YYYY
FE FS PE
PE exam discipline PS Oral examination ...............
PE hours
PS hours
Other ...................................
Has disciplinary action been taken against applicant? YES >> IF YES, PLEASE INCLUDE SOURCE OF SUPPORTING DOCUMENTATION
