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_____________________________________________