Georgia Pe Comity Details

In the list, there's some information concerning the georgia pe comity application. You will have the likely time it'd take you to prepare the form and some additional details.

QuestionAnswer
Form NameGeorgia Pe Comity Application
Form Length13 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 15 sec
Other namesgeorgia pe license comity, comity application on the georgia licensure, georgia pe reciprocity, georgia professional engineer comity application

Form Preview Example

GEORGIA STATE BOARD OF PROFESSIONAL ENGINEERS & LAND SURVEYORS

237Coliseum Drive • Macon, Georgia 31217 • (478) 207-2440 www.sos.ga.gov/plb/pels/

APPLICATION FOR CERTIFICATE AS A PROFESSIONAL ENGINEER

Application Fee $70 (non-refundable)

License Type: PROFESSIONAL ENGINEER

Additional License Types (currently or previously issued by the Georgia Professional Licensing Boards): ___________________________________

Method Obtained by: Applicant is applying for above referenced license by: Comity Original PE license from the State of _______________

Name as desired on License (First, Middle, Last, Suffix): ________________________________

Name as shown on exam records or transcripts (First, Middle, Last, Suffix):

(if different) _____________________________________

Social Security Number: ____ -____-_______ Date of Birth: ___/___/_____

Physical Address: # Street __________________ Apt/Ste: ______ City: ______ State ___ Zip _____

P.O. Box not acceptable for Physical Address

Mailing Address: # Street __________________ Apt/Ste: ______ City: ______ State ___ Zip _____

(if different)

Telephone Day: (____) ____- _____ Telephone Evening: (____) ____-_____

E-Mail Address: __________________________

Affiliation:

Name of firm: __________________________________________

Physical Address: # Street __________________ Apt/Ste: ______ City: ______ State ___ Zip _____

P.O. Box not acceptable

Mailing Address: # Street __________________ Apt/Ste: ______ City: ______ State ___ Zip _____

(if different)

NOTE TO APPLICANT: This information will be entered into the Division database for Accounting and Licensing purposes. All items must be completed, and then duplicated on the next page of the application for Board review.

APPLICATION FOR REGISTRATION AS A PROFESSIONAL ENGINEER BY COMITY

Note: NCEES Record Holders are required to completely fill out sections 1 through 5. NCEES Record Holders are not required to submit endorsements, verification of licensure/exams or transcripts as those items are part of the NCEES Record.

Section 1: General Information

Date: ____________________

 

 

Name (First, Middle, Last, Suffix): ___________________________________________________________

 

Home Address: # Street __________________ Apt/Ste: ______ City: ______ State ___ Zip _____

 

Preferred address: # Street __________________ Apt/Ste: ______ City: ______ State ___ Zip _____

 

Social Security Number: ____-___-_____ Birthplace: ________________ Date of Birth: ___/___/_____

 

Business Phone: (_____)_____ - ______________ Home Phone

(_____) _____ - ________________

 

 

 

 

Have you ever been convicted or pled nolo contender, pled guilty, or been given first offender status for

 

 

any offense status for any offense which is a felony, misdemeanor, a crime violating a federal law

Yes

No

involving controlled substance or dangerous drug, or a DUI or DWI? If yes, provide documentation.

 

 

Have you ever had a licensed that was revoked, suspended, restricted, probated, or surrendered to any

 

 

licensing board or agency? If yes, provide documentation.

 

Yes

No

Have you ever been found liable in civil court of any misconduct, fraud, or negligence in the practice of

 

 

engineering or land surveying? If yes, provide documentation.

 

Yes

No

Has any professional license granted to you been revoked, suspended or otherwise sanctioned publicly

 

 

or privately, or have you ever been denied license, by any board or agency in Georgia or any other

Yes

No

state? If yes, provide documentation.

 

 

 

Do you hold a current NCEES Record that you plan to submit? If yes, contact NCEES for record to be

 

 

sent electronically to the GA Board and complete all of sections 1 through 5 of this application.

Yes

No

Are you currently registered as a Professional Engineer in the state where you live?

 

 

If no, why not? _________________________________________________

Yes

No

 

 

 

 

Has your name changed since birth?

 

 

 

If yes, why? ____________________________________________________

Yes

No

 

 

 

 

Have you ever applied to this Board for registration before?

 

 

 

If yes list when and what type of application _________________________________________

Yes

No

 

 

 

 

Which one branch of engineering do you propose to practice in the state of Georgia? _________________

Designate the special branches of engineering in which you have been examined: ___________________

Present Employer __________________________________________ Position: ___________________

Note: It is the Board’s policy for Comity applicants who practice or propose to practice Structural Engineering and have taken the PE exam in a discipline other than Structural, to have a minimum of 60 months of Structural engineering experience after successful examination acceptable to the Board at the time of application.

Revised 07-12

Section 2: Registration

PE COMITY

EIT-State ____________ Certificate No ____________

Date of Certification as EIT: ___/___/_______

Number of hours written exam (“0” if no written examination taken): ______

PE-State _____________ Certificate No ____________

Date of first registration as a PE ____/____/________

If registered by written exam, indicate number of hours for the exam (“0” if no exam taken): ____

Indicate exam options taken: _______________________

List all states in which you are currently registered as a PE: _______,_______,_______,_______,_______

List other states and types of registration for which you have applied or are currently applying but do not have final notification of registration: _______,_______,_______,_______

NOTE: If you hold an NCEES Council Record and plan to submit it in lieu of endorsements, verification of licensure/exam and transcripts, then you should completely fill out Sections 1 through 5 of this application and contact NCEES to have them electronically transmit your NCEES record to the Georgia Board for consideration. For further information regarding an NCEES Council Record, please contact NCEES at www.ncees.org or 1-800- 250-1396.

NOTE: If you do not hold an NCEES Council Record, you will need to bundle and send with your application:

Official transcripts for each college attended, whether you graduated or not

Evaluation of foreign degree (if you earned your bachelor’s degree outside the US) from an approved provider. If you choose not to have an evaluation, you will need to send a letter indicating so.

Verification of original exam/licensure of both the EIT and PE, and if different, verification of licensure from the state where you live now. If you are not licensed in your residence state, indicate in Section 1.

Endorsements for all experience you list in Section 3. You must have at least five endorsements/references from five (5) individuals, three (3) of which must be currently active PE’s, that are not related to you by

blood or marriage, are not Board members and who have personal knowledge of your engineering experience, reputation and accomplishments.

All of the above supporting documentation must be sent to the Board in sealed envelopes, with the back flap signed to ensure no tampering. Some states/agencies/individuals prefer to send their documentation directly to the Board, which is permissible. This information will be maintained at the Board office and added to the application file upon receipt.

NOTE: Be sure to sign your application and have your signature notarized (Section 5.)

 

Board Use Only Section:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School______________________________________

Degree/Date____________________________Abet Yes_________No__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Masters_____________________________________

Degree/Date____________________________Abet Yes_________ No__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Technology__________________________________

Degree/Date____________________________ Abet Yes_________No__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other_______________________________________

Degree/Date____________________________ Abet Yes_________No__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIT/Date Obtained___________ _________ PE/Date Obtained____________________Discipline__________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3: Engineering Experience

 

 

 

 

 

 

 

 

 

 

 

PE COMITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Engmt

 

 

 

 

Part

From

To

Total

 

%

 

 

Qex

 

%

 

 

Qex

 

%

 

 

Qex

 

 

%

 

 

Qex

 

%

 

 

Qex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#

Company Name

Your Title

 

Time?

mm/yy

mm/yy

Months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL NUMBER OF ENDORSEMENTS FORMS: _______

 

 

 

 

 

 

 

 

 

 

Education Total

 

 

 

 

 

 

NCEES Record Requested in lieu of endorsements Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Field:

 

 

 

 

Experience Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References: Positive

(

)

 

 

Total Months

 

 

 

 

 

 

Negative

(

)

 

 

 

 

 

 

 

 

 

Special:

 

 

 

 

Board Member’s Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shaded areas are for Board use only

 

 

 

 

 

 

 

Note: List all engagements of engineering experience beginning with the earliest and ending with your current position. Endorsement form (Section 6) should correspond with this section. All engagements listed must be described on an endorsement form and someone familiar with your work (preferably your supervisor) should endorse it.

Section 4: Education

 

 

 

 

PE COMITY

 

 

 

 

 

 

 

INSTITUTION AND LOCATION

FROM

TO

Date of

 

 

 

 

 

 

 

 

 

 

 

 

 

Mo/Yr

Mo/Yr

Graduation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High Schools: (Transcripts not needed)

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

Colleges and Universities: (Transcripts

needed from all schools ever attended listed unless applicant is submitting NCEES record)

FROM

Mo/Yr

TO

Mo/Yr

TOTAL MONTHS

MAJOR FIELD

DEGREE EARNED

1.

2.

3.

4.

5.

Section 5: Affidavit by Applicant

I hereby swear and affirm that all information provided in this application is true and correct to the best of my knowledge and belief. I further swear and affirm that I have read and understand the current state laws and rules and regulations of the Georgia State Board of Registration for Professional Engineers and Land Surveyors, and I agree to abide by these laws and rules, as amended from time to time.

By signing this application, electronically or otherwise, I hereby swear and affirm one of the following to be true and accurate pursuant to O.C.G.A. § 50-36-1:

1)_______I am a United States citizen 18 years of age or older. Please submit a copy of your current Secure and Verifiable Document(s) such as driver’s license, passport, or other document as indicated on page 12 of the application.

2)_______I am not a United States citizen, but I am a legal permanent resident of the United States 18 years of age or older, or I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of age or older with an alien number issued by the Department of Homeland Security or other federal immigration agency. Please submit a copy of your current immigration document(s) which includes either your Alien number or your I-94 number and, if needed, SEVIS number.

In making the above attestation, I understand that any failure to make full and accurate disclosures may result in disciplinary action by the Georgia State Board of Registration for Professional Engineers and Land Surveyors and/or criminal prosecution.

State of _________, County of ______________Applicant's Signature_______________________________

Subscribed and sworn to before me this_________day of _____________ , 20______

___________________________________________________(SEAL)

Signature of Notary Public

My commission expires:________/_______/_________

NON-ENGINEERING AND RELATED GAPS

PE COMITY

PLEASE LIST (references not needed)

 

Applicant Name: ____________________________________________

 

If no gap information is needed to be entered, check here:

 

From _______________To ______________

Description ___________________________________________________

From _______________To ______________

Description ___________________________________________________

From _______________To ______________

Description ___________________________________________________

From _______________

To ______________

Description

___________________________________________________

 

 

From _______________

To ______________

Description

___________________________________________________

 

 

 

This is page 1 of a two-page form. Please return both pages stapled together.

PE COMITY

Section 6: Endorsement Form

 

SECTION 6-A (TO BE COMPLETED BY APPLICANT)

 

Name: __________________________________________________________

 

Engagement # as listed in Section 3: _______ Social Security Number_____-____-___________

 

This endorsement is for: Reference & Experience Verification

Reference Only

Experience Verification Only

GA Law Section 43-15-15(d) states: “An application shall contain the names of not less than five persons, not related to the applicant by blood or marriage, of whom at least three shall be registered, active professional engineers…having personal knowledge of the experience on which the applicant predicates his qualifications.”

Experience described on this form was obtained while employed by (company name): ___________________________

Street Address: _____________________________ City: _______________ State: ________ Zip: _________

For this engagement, please provide name of direct supervisor: ___________________________________________

Was your direct supervisor a registered PE? Yes

No

Other: ___________________________________________

Endorser for this engagement: _____________________________________________

State your title(s) & Name of Company. Describe experience (one line is not sufficient) detailing in first person the work you personally performed in design, study, review, testing or other tasks which required your engineering skills. This work should be progressive in difficulty and magnitude; demonstrate sufficient breadth and scope, not a narrow technical skill focus; and reflect the acquired ability to design and apply engineering principles to demonstrate that your judgment may be trusted on projects involving public health and safety. Do not attach resume or project lists. Experience must be verified by PE associates even if you are self-employed.

 

 

Dates

 

Engagement

 

 

 

 

#:

 

From

 

To

 

 

Mo/Yr

 

Mo/Yr

 

___/_____

 

___/_____

 

 

Type of Experience

%

 

 

 

Engineering Design

 

 

 

 

Engineering Studies, Reports, Evaluations

 

 

 

Engineering Research, Data Preparation &

 

Interpretation

 

 

Title: ______________________________________________

Name of Company: __________________________________

Experience Description:

Other Engineering Related Activities

Non-Engineering (including surveying)

Accurate

Section 6B – To Be Completed by Endorser

Applicant’s description in Section 6A above is:

Inaccurate Explain if inaccurate: ____________________________________________________________

Were you the applicant’s direct supervisor for this engagement?

Yes

No

If direct supervisor, were you a registered engineer?

Yes

No

State Registered/#: ______________________

Discipline: ____________________________________ Date of Issue: ___________________________________________

Signature: _________________________________________________

This is page 2 of a two-page form. Please send both pages stapled together.

PE COMITY

Section 6-C (to be completed by the endorser/reference)

 

The Georgia Board prefers that you mail this form back to the applicant in the applicant’s enclosed pre-addressed stamped envelope. Seal the envelope and sign the back flap to ensure against tampering. If you prefer to mail the form directly to the Board office at 237 Coliseum Drive, Macon, GA 31217-3858, please make a blank copy of this form and mail it back to the applicant following the directions above, then mail the completed form to the Board.

Name of Applicant: ____________________________________________________

1a. How well do you know the applicant:

very well

well

slightly

not at all

1b. List dates (months and years) of contact with the applicant: __________________ to _____________________

1c. Basis of contact:

As the applicant’s PE supervisor

As an associate or co-worker in Engineering work

Other (explain): __________________________________

Are you related by blood or marriage?

Yes

No

2.Do you have personal knowledge of the applicant’s engineering work?

Yes

No If yes, complete entire form.

If no, complete only items 3 & 10.

3.What is your opinion of the applicant’s personal integrity and reputation? __________________________________________

4. Would you employ applicant in a position of trust: Yes

No If no, explain: __________________________________

5.Using the interpretation below, please rate the practice and quality of performance of the applicant’s engineering work.

Type of Practice

Responsible Charge

Above

Average

Below

Unsatisfactory

Unknown

 

Yes

No

Average

 

Average

 

 

Engineering Design

 

 

 

 

 

 

 

Engineering Studies

 

 

 

 

 

 

 

Engineering Data Interpretation

 

 

 

 

 

 

Engineering Other

 

 

 

 

 

 

 

Interpretations:

 

 

 

 

 

 

 

Above Average:

Performance unquestionably of a professional level demonstrated through competence and creative ability.

 

Average:

Work not distinguished in content or level, but adequate for engineering purposes indicating an ability, under some supervision, to produce

 

workable design of systems and products.

 

 

 

 

 

 

Below Average:

Performance needs careful checking and rather close supervision to meet requirements.

 

 

 

Unsatisfactory:

Inadequate for “the purpose of safeguarding life, health and property.”

 

 

 

 

Unknown:

Did not review work or work with applicant in this area. Cannot determine proficiency.

 

 

 

6.Licensure in Georgia is not by classification of any discipline of Engineering practice. However, the Board is interested in the applicant’s background and experience and appreciates your appraisal in selecting the discipline in which the applicant is most proficient.

Civil Breadth with Depth in:

Environmental

Geotechnical

Structural

Transportation

Water Resources

Structural I

Electrical

Environmental

Mechanical

Other ______________________

7. Considering the need to protect the public health, safety and welfare, in your opinion how does this applicant rank in professional

competence and responsibility:

Qualified

Additional Experience Needed

Unqualified

8.Remarks: The Board will appreciate additional information or amplifying information regarding the applicant’s engineering experience, capabilities, or limitation, if any. Use reverse side for continuation of comments, if necessary.

_______________________________________________________________________________________________________

9.Based on the definition of the practice of engineering, GA Law 43-15-2(11), do you recommend the applicant for PE licensure?

Yes

No

10.I certify that the above statements are true and correct to the best of my personal knowledge, not made for the purpose of aiding an unqualified applicant to become licensed but with full realization of the responsibility toward the public where the safeguarding of life, health and property is concerned or involved.

Print Name: ____________________________________________________________________________________________

FirstMILast

State of PE License/Number: __________________ Date Issued: _____________ Discipline: __________________________

Present Position: ______________________________________ Firm: ____________________________________________

Address: _____________________________________________

Daytime Phone: (_____) _________________________________

Signature: ______________________________Date: __________

SEAL

If licensed, please verify with professional engineer seal with signature.

Georgia State Board of Registration for

Professional Engineers & Land Surveyors

VERIFICATION OF OUT-OF-STATE LICENSURE

EXAMINATION AND REGISTRATION

Instructions to the Applicant:

1.The Applicant should:

a.Complete his or her name and address on the top portion, upper right corner on the reverse side of this form.

b.Fill in the name of the state board completing this form.

c.Forward this form to the out-of-state board where the applicant is certified or registered.

2.Comity Applicants should:

a.Submit a form to the state of their Engineer-In-Training (EIT) and to the state of their initial Professional Engineer (PE) registration.

b.If registration is not currently valid in the state of the initial registration, submit a form to the state where a current valid registration is held.

c.If the applicant currently lives in a state other than initial licensure, submit a form to that state. If the applicant is not licensed in the state of residence, please indicate in Section 1 of the application.

3.This form may be copied if necessary.

Notes to applicant:

1.It is the policy of some states/agencies is to only send the verification/documentation directly to the Georgia Board rather than to the applicant. This is permissible.

2.It is the policy of some states/agencies to charge a fee for verification and if so, the state will not process the request until the fee is received. Before you mail this verification request to the state Board, check their website or call them to verify their fee policy.

Instructions to the Out-of-State Board:

The Out-of-State Board should complete Sections 1 - 4 on the reverse side of this form, enter the appropriate state name, and return to the applicant in a sealed envelope with an official signature on the flap of the envelope to assure no tampering. The Georgia Board will not accept this form to be transmitted via e-mail or fax.

REQUEST FOR VERIFICATION OF REGISTRATION OR EXAMINATION FOR PE COMITY APPLICANT

TO (State Requested): ________

Date:

_______________

 

 

 

 

Name:

_____________________________________________

FROM: GA Board of PELS

Address:

_____________________________________________

237 Coliseum Drive

 

_____________________________________________

Macon, GA 31217

City:

________________

State: ____

Zip:

________

 

SSN:

____-____-_______

DOB:

____/____/______

1.THE ABOVE NAMED PERSON WAS CERTIFIED OR REGISTERED AS:

 

Certificate

Date

Valid Until

 

#

Issued

 

 

Engineer-In-Training/Engineer Intern……………………..

________

________

________

________

________

________

Professional Engineer………………………………………

________

________

________

Land Surveyor-In-Training/Land Surveyor Intern…………

________

________

________

Land Surveyor………………………………………………..

________

________

________

2.BASIS OF REGISTRATION:

 

 

 

(Pass/Fail)

(Yes/No)

 

 

 

Hours

Results

NCEES

Exam Date

Written Examination:

FE

________

________

________

________

 

PE

________

________

________

________

 

FLS

________

________

________

________

 

LS

________

________

________

________

Other

Other

________

________

________

________

Examination Option:

_________________________________________________(Discipline)

Oral Examination:

Hours PE _____________

Hours LS ___________________

EIT/LSIT Accepted from: ___________________________________________________________

PE/LS Accepted from:

___________________________________________________________

Other: ____________________________________________________________________

3.QUESTIONS:

1.

Has any disciplinary action ever been taken against the applicant?

Yes

No

2.

If so, has this disciplinary case been satisfied to the Board’s requirements?

Yes

No

 

(If not, give details):

 

 

4. REMARKS:

(BOARD SEAL)

 

By:_____________________________________ Title:___________________________ Date:__________

Verifying State:____________________________

(If a fee is required, please notify the applicant but do not delay the processing of this form)

OFFICE OF SECRETARY OF STATE

PROFESSIONAL LICENSING BOARDS DIVISION

237 Coliseum Drive

Macon, Georgia 31217

(478) 207-2440

CONSENT FORM

I hereby authorize the Board of Registration for Professional Engineers and Land Surveyors (“Board”) to receive any Georgia criminal history record information pertaining to me which may

be in the files of any state or local criminal justice agency in Georgia.

________________________________________________________________________

Full Name (Print)

________________________________________________________________________

________________________________________________________________________

Physical Address (P.O. Boxes NOT Accepted)

 

__________

____________

____________________

_________________

Sex

Race

Date of Birth

Social Security Number

One of the following must be checked:

This authorization is valid for 90/180/___ (circle one) days from date of signature.

I, _______________________________________ give consent to the Board to perform

periodic criminal history background checks for the duration of my licensure with this state.

_________________________________

____________________

Signature of Applicant

Date

Special licensure provisions (check if applicable):

 

____ Working with mentally disabled

 

____ Working with elder care

 

____ Working with children

 

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOU POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATE DOCUMENTATION.

Name ________________________________________

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot later than August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(f). The Attorney General may modify this list on a more frequent basis, if

necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50-36-2, contains documents that are verifiable for identification purposes, and documents on this list may not necessarily be indicative of residency or immigration status.

_____ A United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the

Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____An identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the

Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A tribal identification card of a federally recognized Native American tribe, provided that it contains a photograph of the bearer or lists

sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer. A listing of federally recognized Native American tribes may be found at: http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.htm [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A passport issued by a foreign government [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR

§ 274a.2]

_____A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

_____A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

_____A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A. §50-36-2(b)(3); 22 CFR § 41.2]

_____A driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-560 or Form

N-561) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

_____A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-550 or

Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

_____In addition to the documents listed herein, if, in administering a public benefit or program, an agency is required by federal law to accept a

document or other form of identification for proof of or documentation of identity, that document or other form of identification will be deemed a secure and verifiable document solely for that particular program or administration of that particular public benefit. [O.C.G.A. § 50-36-2(c)]