Carryover Details

Form Pes 4012 is the form taxpayers use to request a withholding certificate from their employer. The certificate allows taxpayers to specify the amount of income tax their employer should withhold from their wages. Taxpayers who do not submit Form Pes 4012 to their employer may have too much or too little income tax withheld from their paychecks, which could result in a tax refund or balance due when they file their taxes.

Before you decide to fill in form pes 4012, you should find out more about the type of form you'll use.

QuestionAnswer
Form NameForm Pes 4012
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesaspx, CPD, pes, cpd log

Form Preview Example

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

 

Continuing professional development (CPD) activity log

4012

All CPD activities and courses must be relevant to the practice of engineering or surveying and must include technical, ethical or managerial content. This form is required for tracking your CPD hours for Ohio P.E. and P.S. registration annual renewal. This form does not replace copies of your certificates of completion or other documentation required by Ohio Revised Code section 4733.151. Fifteen CPD hours are required for Ohio registration renewal. A maximum carryover of 15 CPD hours are allowed per year. For information about the Board’s CPD requirements, go to our website at www.peps.ohio.gov/ContinuingEducation.aspx.

YOUR OHIO P.E., P.S. REGISTERED NAME AS IT IS ON YOUR LICENSE

 

 

P.E. NUMBER

 

 

P.S. NUMBER

FOR CALENDAR YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

0

 

0

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

SPONSOR /

 

 

 

LOCATION:

ACTIVITY TITLE,

 

 

 

 

 

CPD

DOCUMENTATION

[MM/DD]

PROVIDER

 

 

ADDRESS, CITY, STATE, ZIP

DESCRIPTION

INSTRUCTOR

 

EARNED

 

 

RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2008 CPD

 

TOTAL

TOTAL

 

The CPD credits listed herein are true and correct, and accurately state the professional development hours I have earned.

CARRIED OVER

 

2009 CPD

CPD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MAXIMUM 15)

 

EARNED

EARNED

 

SIGNATURE

 

 

 

 

 

 

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Board of Registration for Professional Engineers and Surveyors

50 West Broad Street, Suite 1820 • Columbus, Ohio 43215-5905

VOICE (614) 466-3651FAX (614) 728-3059U.S. TOLL FREE (877) 644-6364 (877) OHIO ENG EMAIL pes.board@pes.ohio.gov • WEB www.peps.ohio.gov

PES 4012 (Rev. 01/2009)

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