Form Pes 1011 Ps PDF Details

Form Ps 1011 is a declaration of the state of Florida's property tax exemption for veterans. The form must be completed by the veteran, or their surviving spouse/dependent, to claim an exemption from ad valorem taxes on real property owned by the veteran as of January 1st of the year for which the exemption is being claimed. Certain qualifications must be met in order to qualify for this exemption, which are outlined on the form. Claims can be filed at any time during the year, but no later than December 31st. For more information and details on how to file your claim, please visit our website or contact our office. Thank you for your service!

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Form NameForm Pes 1011 Ps
Form Length6 pages
Fillable?No
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Avg. time to fill out1 min 30 sec
Other namesboardpes, ps form 1011, OHIO, liteblue gov usps employees forms ps form 1011

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OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS BOARD USE ONLY

1011-pS

 

pS Exam Approval Application

 

Registration qualiications

this PS Exam Approval Application is oNlY for candidates who are applying to take an ncEES Principles and Practice of Surveying examination for the irst time in ohio. registration qualiications can be found in ohio r.c. section 4733.11 through section 4733.13 and ohio A.c. section 4733-9. Your initials are required in several

locations, and a notarized afidavit is required on Page 4. An incomplete application cannot be reviewed and will be returned.

<< Your initials indicate that you have read the registration qualiications.

$75.00 nonrefundable application fee

An application and fee is required for each exam cycle. A $75.00 nonrefundable application fee, using check or money order; and made payable in u.S. funds to Treasurer, State of ohio; is required by ohio r.c. section 4733.12, section 4733.13 and ohio A.c. section 4733-19.

<<Your initials indicate that you understand the nonrefundable application fee is required by Ohio law and that the Board only accepts check or money order. Applications with cash will be returned.

contact, personal information

rEAd dIScLoSurE StAtEmEnt, PrIVAcY notIcE on PAgE 4

the Board requires your full name as it will oficially appear on any subsequent certiicate of registration. ImpoRTANT! We must assume your name is in u.S. order — irst, middle, last. Initials may be used. Your name on this application, and any subsequent ncEES- administered examination registration, must be the same.

Your fuLL nAmE In u.S. ordEr — fIrSt, mIddLE, LASt — InItIALS mAY BE uSEd

SuffIX

 

 

 

 

mAILIng AddrESS LInE 1

 

p.o. box is NoT acceptable

 

 

 

 

 

 

 

 

 

 

 

 

mAILIng AddrESS LInE 2 >> oNlY if needed

 

 

 

 

 

 

 

 

 

 

 

 

cItY

 

 

 

 

 

 

 

 

 

 

 

 

 

u.S. StAtE, ZIP

cAnAdA ProVIncE, PoStAL codE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EmAIL AddrESS

 

 

 

 

 

 

 

tELEPHonE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Required photo

Your REQUIREd photograph must be securely attached within this 2" by 2" space.

Passport, or passport-style, photo is requested.

required, by ohio A.c. section 4733-17, is a permanent print of your recognizable face not less than ¾" wide.

u.S. SocIAL SEcurItY numBEr

REQUIREd by ohio R.c. section 3123.50

BIrtH dAtE >> mm/dd/YYYY

countY >> REQUIREd if ohio address

countrY >> only if NoT U.S. or canada

Higher education oHIo A.c. SEctIon 4733-17

ImpoRTANT! only AbET and board-approved degrees are accepted for an FS exam approval. go to www.peps.ohio.gov for Board policy and degree evaluation information. credit claimed must be supported by an oficial transcript from the institution. Applications iled without original transcripts cannot be reviewed until transcripts are received.

InStItutIon

from

to

grAduAtEd

dEgrEE EArnEd

college or university

mm/YY

mm/YY

mm/YY

AbET or board-approved degree oNlY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Surveying courses worksheet attached? rEQuIrEd for APPLIcAntS WItH cIVIL EngInEErIng dEgrEE

no

Yes: the surveying courses worksheet, PES 1012, is included with this application.

PES 1011-PS (rev. 09/2012) 0903

Page 1 of 4

Surveying exam, licensure information VErIfIcAtIon rEQuIrEd for non-oHIo EXAm, LIcEnSE

FS exam

 

current p.S. licensure LISt no morE tHAn 3

StAtE EXAm dAtE >> mm/dd/YYYY S.I. cErtIfIcAtE numBEr [1]

 

StAtE P.S. cErtIfIcAtE numBEr

EXP. dAtE >> mm/dd/YYYY

 

 

 

 

 

 

 

 

 

 

 

pS exam

StAtE EXAm dAtE >> mm/dd/YYYY P.S. cErtIfIcAtE numBEr

Engineering exam, licensure information VErIfIcAtIon rEQuIrEd for non-oHIo EXAm, LIcEnSE

FE exam

 

current p.E. licensure LISt no morE tHAn 3

StAtE EXAm dAtE >> mm/dd/YYYY E.I. cErtIfIcAtE numBEr [1]

 

StAtE P.E. cErtIfIcAtE numBEr

EXP. dAtE >> mm/dd/YYYY

 

 

 

 

 

 

 

 

 

 

 

pE exam

StAtE EXAm dAtE >> mm/dd/YYYY P.E. cErtIfIcAtE numBEr

PE EXAm dIScIPLInE

[1]NoTE: S.I. and E.I., formerly S.I.t. and E.I.t., are ohio’s abbreviations for Surveyor Intern and Engineer Intern. Some states, including ohio, do not issue surveyor intern or engineer intern numbers.

References oHIo r.c. SEctIon 4733.12

List 5 persons, at least 3 of whom are registered 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

nAmE

 

BuSInESS rELAtIonSHIP

P.S./P.E. rEgIStrAtIon

 

Number

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AddrESS

 

 

 

occuPAtIon

 

 

 

 

 

 

 

 

 

2

nAmE

 

BuSInESS rELAtIonSHIP

P.S./P.E. rEgIStrAtIon

 

Number

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AddrESS

 

 

 

occuPAtIon

 

 

 

 

 

 

 

 

3

nAmE

 

BuSInESS rELAtIonSHIP

P.S./P.E. rEgIStrAtIon

 

Number

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AddrESS

 

 

 

occuPAtIon

 

 

 

 

 

 

 

 

4

nAmE

 

BuSInESS rELAtIonSHIP

P.S./P.E. rEgIStrAtIon

 

Number

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AddrESS

 

 

 

occuPAtIon

 

 

 

 

 

 

 

 

5

nAmE

 

BuSInESS rELAtIonSHIP

P.S./P.E. rEgIStrAtIon

 

Number

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AddrESS

 

 

 

occuPAtIon

 

 

PES 1011-PS (rev. 09/2012) 0903

Page 2 of 4

Experience oHIo A.c. SEctIon 4733-9

What is the nature and extent of your experience? do not list college education. make as many copies of this page as needed. If using plain sheets to furnish additional engineering experience, be sure to date and sign each additional sheet. Include title of your position, name and location of employer, character of each employment and degree of responsibility. Explain your surveying experience in suficient detail to indicate degree of responsibilities and work performed. Have your supervisor complete and sign the supervisor information. If the supervisor is unavailable or unwilling to provide the information, attach a letter to this application with an explanation. You should only list fulltime employment.

from

to

EXPErIEncE dEtAIL

mm/YY

mm/YY

position, employer, location, work responsibilities

 

 

 

 

tImE

Years months

PErcEntAgE (%) of tImE

Surveying Engineering

SuPErVISor InformAtIon

Supervisor must complete

nAmE

P.S./P.E. rEgIStrAtIon

NumberState

EmAIL >> optional

tELEPHonE

SIgnAturE

dAtE

from

to

EXPErIEncE dEtAIL

mm/YY

mm/YY

position, employer, location, work responsibilities

 

 

 

 

tImE

Years months

PErcEntAgE (%) of tImE

Surveying Engineering

SuPErVISor InformAtIon

Supervisor must complete

nAmE

P.S./P.E. rEgIStrAtIon

NumberState

EmAIL >> optional

tELEPHonE

SIgnAturE

dAtE

from

to

EXPErIEncE dEtAIL

mm/YY

mm/YY

position, employer, location, work responsibilities

 

 

 

 

tImE

Years months

PErcEntAgE (%) of tImE

Surveying Engineering

SuPErVISor InformAtIon

Supervisor must complete

nAmE

P.S./P.E. rEgIStrAtIon

NumberState

EmAIL >> optional

tELEPHonE

SIgnAturE

dAtE

PES 1011-PS (rev. 09/2012) 0903

Page 3 of 4

disciplinary actions oHIo r.c. SEctIon 4733.20

FEloNY, moRAl TURpITUdE Have you been convicted, found guilty, pled guilty 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 statement(s) and

 

 

supporting documentation to this application. documentation should include, but is not limited to, court and

 

 

police records.

lIcENSE, REGISTRATIoN Have you had a disciplinary action involving 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 statement(s) and

 

 

supporting documentation to this application.

disclosure statement, privacy notice

dIScloSURE STATEmENT the State Board of registration for Professional Engineers and Surveyors is requesting disclosure of information that is necessary to accomplish our statutory purpose as required by chapter 4733 of the revised code and Administrative code. failure to provide required information may result in your application approval being delayed or in your application being returned.

pRIVAcY NoTIcE most documents and records maintained by the state of ohio are public records under ohio law. this means that information submitted to us from you may be subject to disclosure if there is an oficial public records request. EXcEpTIoNS: Your u.S. social security number and any college transcripts submitted to the Board are NoT public records and cannot be released through a public records request.

<< Your initials indicate that you have read the disclosure statement, privacy notice.

Notarized afidavit oHIo r.c. SEctIon 4733.09

StAtE of

AFFIANT

I,

 

,

being the duly sworn, or afirmed, applicant say that my statements in this application are true to the best of my knowledge and belief.

AffIAnt SIgnAturE

NoTARY

Subscribed and sworn, or afirmed, to me this

day of

 

,

 

.

Witness my hand and seal hereon.

notArY SIgnAturE

 

L

 

A

S

E

 

Y

 

R

N

O

T

A

R

Y

dAtE SIgnEd

 

mY commISSIon EXPIrES

 

 

 

A

T ON

 

E

S

 

 

L

A

 

 

 

[ tHIS SPAcE IntEntIonALLY BLAnK ]

deliver completed pS Exam Approval Application with fee to:

pS EXAm AppRoVAl ApplIcATIoN StAtE BoArd of rEgIStrAtIon for ProfESSIonAL EngInEErS And SurVEYorS 50 W BroAd St StE 1820

coLumBuS oH 43215-5905

Questions?

EmAIL pes.board@pes.ohio.gov

(614) 728-3059 fAX

(877)644-6364 u.S. toLL frEE

(614)466-3651 coLumBuS mEtro

PES 1011-PS (rev. 09/2012) 0903 Page 4 of 4

OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS

BOARD USE ONLY

1012

Surveying courses Worksheet

this Surveying courses Worksheet must be completed by applicants seeking eventual registration in ohio as a Professional Surveyor who do not have a B.S. degree in surveying. ohio r.c. section 4733.11 (B) allows an applicant with an EAc/ABEt-accredited B.S. degree in civil Engineering (B.S.c.E.) to be eligible for eventual registration as a Professional Surveyor if the applicant has completed 16 semester hours (or 24 quarter hours) of Board-approved surveying courses,

including at least 6 semester hours (or 8 quarter hours) of courses in property surveying. the course category requirements are listed below. This form must be accompanied by original transcripts showing a b.S.c.E. degree and completion of the courses listed herein. underline the surveying courses on your submitted transcripts.

 

Your fuLL nAmE In u.S. ordEr — InItIALS mAY BE uSEd

 

 

u.S. SSn

 

dAtE SuBmIttEd

 

FIRST, mIddlE, lAST

 

 

 

lAST 4 oNlY

 

mm/dd/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

list courses in correct categories

 

 

 

totAL

BoundArY

 

 

 

crEdIt

SurVEYIng

 

 

 

 

 

 

 

HourS

crEdIt

 

 

courSE tYPE

courSE numBEr

coLLEgE or unIVErSItY

 

SEm QTR

SEm QTR

 

 

 

 

 

 

 

 

 

 

 

 

Boundary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

oneleastathavemustcourse categoriesiveirsttheofeachin

 

surveying

 

 

 

 

 

 

 

 

courses1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

control

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

surveying2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Historic develop-

 

 

 

 

 

 

 

 

 

 

ment of ohio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

surveying

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

route or

 

 

 

 

 

 

 

 

 

 

construction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

surveying3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ohio minimum

 

 

 

 

 

 

 

 

 

 

standards laws

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and ethics

upper level surveying courses4

Totals

1must include colonial and public land surveying methods and legal description writing

2must include ohio state plane coordinate system

3If construction surveying, must contain horizontal and vertical curve topics

4List any upper level courses

SEm QTR

SEm QTR

must be at least

must be at least

16 semester hours or

6 semester hours or

24 quarter hours

8 quarter hours

ImpoRTANT! this surveying courses worksheet assumes that all required college/university prerequisites to the issued courses and/or subject areas were completed in the B.S.c.E. program. courses such as surveying fundamentals, computer, and cAd courses not part of the B.S.c.E. program, may be required as bridge work by the academic institution offering the required courses in the form of a certiication program.

SURVEYING coURSES WoRKSHEET StAtE BoArd of rEgIStrAtIon for ProfESSIonAL EngInEErS And SurVEYorS 50 W BroAd St StE 1820

coLumBuS oH 43215-5905

Questions?

EmAIL pes.board@pes.ohio.gov

(614) 728-3059 fAX

(877)644-6364 u.S. toLL frEE

(614)466-3651 coLumBuS mEtro

PES 1012 (rev. 09/2012) 0903

Page 1 of 1

OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS

licensure, Examination Veriication Request

use this form only if you acquired your E.I., S.I., P.E. and/or P.S. in a u.S. jurisdiction or state other than ohio.

1.To bE complETEd bY ApplIcANT

nAmE

AddrESS

cItY, StAtE, ZIP

BOARD USE ONLY

1013

u.S. SSn

last 4 oNlY

 

BIrtH dAtE >> mm/dd/YYYY

 

 

 

VErIfIcAtIon rEQuEStEd from

rEQuEStIng VErIfIcAtIon for (cHEcK ALL tHAt APPLY):

E.I.

S.I.

P.E.

P.S.

2.To bE complETEd bY VERIFYING boARd

Applicant is certiied 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 certiied or registered by:

 

NcEES

 

HourS rESuLtS

YES no

EXAm dAtE >> mm/dd/YYYY

Written examination fE

fS

PE

PE exam discipline

PS

other...................................

Has disciplinary action been taken against applicant?

no

YES >> If YES, PLEASE IncLudE SourcE of SuPPortIng documEntAtIon

Veriied by:

PrIntEd nAmE, tItLE

SIgnAturE

dAtE

 

 

VERIFIcATIoNS

StAtE BoArd of rEgIStrAtIon for ProfESSIonAL EngInEErS And SurVEYorS 50 W BroAd St StE 1820

coLumBuS oH 43215-5905

 

L B

O

 

 

A

 

 

S

E

 

A

 

 

 

 

R

D

 

 

D

 

 

 

 

R

 

E

S

A

 

 

 

O

B

A

 

 

 

 

 

 

L

 

Questions?

EmAIL pes.board@pes.ohio.gov

(614) 728-3059 fAX

(877)644-6364 u.S. toLL frEE

(614)466-3651 coLumBuS mEtro

PES 1013 (rev. 09/2012) 0903

Page 1 of 1