professional land surveyor application for licensure
Post on 28-Apr-2022
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PLSComity Reinstatement Ini1al
Check CreditCard ________
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PROFESSIONALLANDSURVEYORAPPLICATIONFORLICENSUREApplica1onsmustbetyped DonottypeinallcapsDonotfold
AllapplicantsmusttakethetwohourNCstatespecificexamina1on.Pleaseselectthedesiredexamperiod(check thecalendarontheBoardwebsiteforspecificdates). January April July October�
A. GeneralInforma1on
1.FullLegalName
_____________________________________________________________________________________________________LASTFIRSTMIDDLESUFFIXMAIDEN
Boardrecords,wallcer-ficateandyoursealwillreflectfirstname,middleini-al,andlastnameunlessanotherpreferenceisindicatedbelow:
____________________________________________________________________________________________________________
2.BirthDate______/______/_________ SSN______–_____–________ E-mail_____________________________________
3.PhysicalResidenceAddress__________________________________________________________________________________
City_______________________________________________State_______Zip_________-_______
4.BusinessName_____________________________________________________________________________________________
5.PhysicalBusinessAddress___________________________________________________________________________________
City_______________________________________________State_______Zip_________-_______
6.PreferredMailing__________________________________________________________________________________________
ApplicaPonNumber
DateReceived
PassportSizedHeadandShoulderPhoto
AVachHere
NCBoardofExaminers
� ForEngineers&Surveyors
7.Bus.Phone______-_______-________ Res.Phone______-_______-________ CellPhone______-_______-________
8.AreyouaU.S.ciPzen? Yes▢ No▢ Ifnot,pleaseaVachdocumentaPonoflegalstatus.
9.Birthplace City___________________________________________ State_______ Country_____________________
10.HaveyoupassedtheFSexaminaPon? Yes▢ No▢ State__________________ Date_______/_______/_________
CerPficaPonNumber_________________________ ComputerBasedTest? Yes▢ No▢
11.HaveyoupassedthePSexaminaPon? Yes▢ No▢ State__________________ Date_______/_______/_________
LicenseNumber_____________________________ ComputerBasedTest? Yes▢ No▢
12.HaveyoupreviouslyappliedforcerPficaPonorlicensureasanSIorPLSinNorthCarolina? Yes▢ No▢
13.HaveyoupreviouslyappliedforlicensureinanyotherjurisdicPonandbeendenied? ***Yes▢ No▢
14.Haveyoueverbeendisciplinedonanyprofessionallicense? ***Yes▢ No▢
15.Haveyoueverbeenconvictedofafelony?(Ifyes,provideproofofrestoraPonofcivilrights.) ***Yes▢ No▢
16.Haveyoueverbeenconvictedofamisdemeanor?(DonotincludeminortrafficviolaPons.) ***Yes▢ No▢
***Ifyes,givedateanddetailsonaseparatepagelabeledaddendum.Iftheanswertoanyoftheseques-onschangesto“Yes”priortotheBoardissuingthelicense,youmustupdateyourapplica-on.
B.Comity
Areyouapplyingforcomity? Yes▢ No▢
Licensurebycomityisgrantedonlytoapplicantslicensedbyexamina-on.
DoyouhaveanNCEESCouncilRecord? Yes▢ No▢ DatesenttoNCBoard_______/_______/________
Number____________________________________
C.EvidenceofExperienceListexperience(EVENTHOUGHITISNOTCLAIMEDASSURVEYING),beginningfromthedateofgradua-ontopresentwithallmonthstofallconsecu-velyin-me,NOGAPS.
Date Month&YearMM/YY
Experiencelis1nginfollowingformat:1.a.TitleofPosiPonb.Nameandaddressofemployer c.DescripPonofwork:Accuratelyandconciselyindicatecharacterofworkanddegreeofresponsibility.Ifyoudesiretoamplifyyourworkrecord,usemorethanoneEvidenceofExperienceform.
Total1meofeachsurveyingemployment
Nameandaddressofanindividual,preferablyaProfessionalLandSurveyor,thoroughlyfamiliarwitheachemploymentandtowhomtheapplicantreported,orwithwhomtheapplicantwasassociated(Iflicensed,indicate“PLS”akername).
From To Experience Years Months Reference
From To Experience Years Months Reference
InaccordancewithChapter89CoftheGeneralStatutesofNorthCarolina,Icer:fytotheaboverecordofexperience,andherebyapplyforlicensureasaProfessionalLandSurveyor.IhavereadanddosubscribetotheRulesofProfessionalConductandbelievethataviola:onofanyoftheseRulesbyaProfessionalLandSurveyorisjus:fiablecauseforrevoca:onoflicensure.
_____________________________________________________SignatureofApplicant
From To Experience Years Months Reference
TOTALSURVEYINGTIME
D.EvidenceofEduca1onApplicanttorequesttranscriptbesentdirectlytoBoard.Highschooltranscriptnotrequiredwhereevidenceofhighersurveyingdegree,orotherequivalentcurricula,isprovided.
E.RequiredReferencesReferencesshouldbeindividualsfamiliarwithyourwork,characterandreputa-on(excludingfamilymembersandcurrentBoardmembers),andtowhomyouhavedistributedReferenceForms.Theburdenofprovinggoodcharacteristheresponsibilityoftheapplicant.ForPLSlicensure,five(5)referencesarerequired,three(3)ofwhichmustbeProfessionalLandSurveyors.TheapplicantmustsendaReferenceFormtoeachpersonlistedbelow.
NameofIns1tu1onCityandState
DatesofAXendance
DateofGradua1on
Curriculum DegreeorCer1ficate
HighSchool
CommunityCollege
Universi1es
NamesandAddressesofReferences IfPLS,stateoflicensure
1.
2.
3.
4.
5.
F.AffidavitTobea[estedbeforeaNotaryPublicorotherofficialauthorizedtoadministeroaths.
STATEOF_______________________________________________ COUNTYOF________________________________________
Onthe___________dayof___________________________,_____________,beforetheundersigned,aNotaryPublicin
andfor________________________________CountyandStateaforesaid,came
________________________________________,aresidentof__________________________________Countyinthe
Stateof_____________________________________knowntomeasthepersonhereindescribed,whosephotograph
appearsonthisapplicaPonforlicensure,andsubscribinghereto,ashavingsignedtheApplicaPonFormaVachedhereto,
andonoathdeposesandsaysthatthestatementsmadehereinaretrue.
SignatureofApplicant_____________________________________________________
(NotarySeal)Subscribedandsworntobeforeme,this________dayof____________________________,_________
SignatureofNotaryPublic__________________________________________________
Mycommissionexpires_____________________________________________
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