Ohio Form 3011 – Fill Out and Use This PDF

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

Certiicate of Authorization application instructions

3010

Each application must include…

•Notarized Certiicate of Authorization application: PES 3011 (Rev. 03/2011).

•Separate notarized Firm afidavit of responsibility for each professional engineer and professional surveyor designated in responsible charge: PES 3012 (Rev. 03/2011).

•An active Ohio Secretary of State charter or registration number authorizing the irm to do business in the state of Ohio. In addition, if a irm is using a doing business as (DBA) name, an active Ohio Secretary of State charter or registration number authorizing the irm’s DBA name to do business in the state of Ohio is needed.

•Appropriate application fee, using check or money order, and made payable in U.S. funds to treasurer, State of Ohio. NEW, ADDITIONAL SERVICE, or NAME CHANGE application fee is $50.00. ANNUAL RENEWAL application fee is $25.00. LATE ANNUAL RENEWAL application fee is $37.50.

Contacting Ohio’s Secretary of State

Contact information for the Ohio Secretary of State’s ofice is provided as a courtesy and may be subject to change.

•On the web www.sos.state.oh.us

•Telephone (877) 767-6446 U.S. toll free or (614) 466-2655 Columbus metro

important checklist information

•Application must be illed out completely. All ields are required unless otherwide indicated.

•Each full-time employee designated in responsible for, and responsible charge of, the professional engineering or pro- fessional surveying activities and decisions must ill out Firm afidavit of responsibility PES 3012 (Rev. 03/2011).

•The full-time employee must be a partner, manager, member, oficer or director and shall be registered in this state. Full- time, as deined in Ohio R.C. section 4733.16, means working more than 30 hours per week or working substantially all the engineering and/or surveying hours for a irm that holds a Certiicate of Authorization.

•The irm and/or its DBA must hold an active registration(s) with the Ohio Secretary of State.

•Applications without the correct fee or with incomplete information will be returned.

•All Certiicates of Authorization expire annually on June 30.

•Failure to renew the Certiicate of Authorization by the June 30 deadline renders the irm inactive and unauthorized to practice in the state of Ohio.

•Firms must notify the Board within 30 days of any change of the irm’s name or address.

•Firms are responsible for notifying the Board within 30 days of any changes of partners, managers, oficers, members, directors, shareholders, designated professional engineers, designated professional surveyors or change of ownership.

•Firms with a name change must ile a new application and include an application fee of $50.00.

•Firms adding an additional service must ile a new application and include an application fee of $50.00.

•Firms that do not wish to renew their Certiicate of Authorization must notify the Board in writing.

•A Certiicate of Authorization is not the same as an individual license to practice professional engineering or professional surveying in the state of Ohio.

Disclosure statement, privacy notice

Ohio’s State Board of Registration for Professional Engineers and Surveyors is requesting disclosure of information that is necessary to accomplish our statutory purposes required by Ohio Revised Code Chapter 4733. Failure to provide required information may result in your approval being delayed or your application being returned. Subject to certain Ohio Revised Code statutory exceptions, most documents and records maintained by the state of Ohio, including those maintained by the Board, 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.

PES 3010 (Rev. 03/2011) 20110301

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

Certiicate of Authorization application

3011

This application is for irms requiring a Certiicate of Authorization in order to provide, or offer to provide, professional engineering and/or professional surveying services in Ohio. Use this application for new, annual renewal and late annual renewal approvals; or for adding an additional service or a name change. All ields required unless otherwise indicated. The appropriate nonrefundable application fee must be included using check or money order and made payable in U.S. funds to treasurer, State of Ohio. An incomplete application — or an application without the appropriate fee — cannot be processed and will be returned.

Application for >> CHOOSE ONLY ONE
$50.00 NEW			$25.00 ANNUAL rENEWAL
$50.00 ADDitiONAL SErviCE			$37.50 LAtE ANNUAL rENEWAL
$50.00 NAME CHANGE
ENTER PREVIOUS FIRM NAME >>

Ohio Certiicate of Authorization number >> rEQUirED unless new irm

Professional services to be offered by irm

Engineering ONLY

Surveying ONLY

Engineering AND Surveying

Firm is registered with the Ohio Secretary of State as

Corporation	LLC	Partnership		Professional Association
Other DESCRIBE FIRM TYPE >>

Firm contact information >> ALL FiELDS rEQUirED UNLESS OTHERWISE INDICATED

An active Ohio Secretary of State (SOS) charter or registration number authorizing the irm to do business in the state of Ohio is required for each irm name and irm DBA name, if used. Contact the Secretary of State at www.sos.state.oh.us.

OHIO SOS NO.		FIRM NAME
OHIO SOS NO. >> rEQUirED with DBA FIRM DBA >> ONLY if using DBA (Doing Business As) name
CONTACT EMAIL ADDRESS				FEDERAL EMPLOYER ID NUMBER

MAiLiNG ADDrESS >> ONLY IF DIFFERENT THAN ABOVE LOCATION		Indicate if change of address
ADDRESS LINE 1	>> DO NOt USE AGENt ADDrESS			TELEPHONE
ADDRESS LINE 2	>> ONLY if needed			COUNTY >> ONLY if Ohio address
CITY				STATE ZIP+4

PES 3011 (Rev. 03/2011)

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

Certiicate of Authorization application

3011

Ownership If irm has more than four owners, attach additional pages with the same information.

1 FIRM OWNER NAME		FIRM OWNER ADDRESS

registered individuals in responsible charge All professional services shall be executed by, or be under the direct supervision of, an Ohio-registered professional engineer or professional surveyor. Pursuant to Ohio R.C. section 4733.16, each corporation, limited liability company, partnership or professional association through which professional engineering or surveying services are offered or provided in Ohio, shall designate one or more directors, partners, managers, members or oficers employed by the irm full time as being responsible for and in responsible charge of the professional engineering or professional surveying activities and decisions of the irm.

Name, registration number, position of registrant in responsible charge iMPOrtANt! Each registrant

listed as in responsible charge must include an accompanying Firm Afidavit of responsibility (PES 3012). If more than four registrants are in responsible charge, attach additional pages with the same information.

1 PRINTED NAME >> include notarized PES 3012iNDiCAtE ALL tHAt APPLY

				Director	Partner	Manager
				Member	Oficer
OHIO P.E. NUMBER		OHIO P.S. NUMBER
2 PRINTED NAME >> include notarized PES 3012				iNDiCAtE ALL tHAt APPLY
				Director	Partner	Manager
				Member	Oficer
OHIO P.E. NUMBER		OHIO P.S. NUMBER
3 PRINTED NAME >> include notarized PES 3012				iNDiCAtE ALL tHAt APPLY
				Director	Partner	Manager
				Member	Oficer
OHIO P.E. NUMBER		OHIO P.S. NUMBER
4 PRINTED NAME >> include notarized PES 3012				iNDiCAtE ALL tHAt APPLY
				Director	Partner	Manager
				Member	Oficer
OHIO P.E. NUMBER		OHIO P.S. NUMBER

PES 3011 (Rev. 03/2011)

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

Certiicate of Authorization application

3011

Additional Ohio P.E., P.S. registrants employed by irm

List registrant name, registration number and irm location address of each Ohio P.E. or Ohio P.S. whose services are employed by the irm as of the date of this application. If needed, attach additional pages with the same information required below.

1 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER
2 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER
3 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER
4 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER
5 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER
6 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER
7 REGISTRANT NAME					FIRM LOCATION ADDRESS
OHIO P.E. NUMBER		OHIO P.S. NUMBER

Disclosure statement, privacy notice

Ohio’s State Board of Registration for Professional Engineers and Surveyors is requesting disclosure of information that is necessary to accomplish our statutory purpose required by Ohio R.C. Chapter 4733. Failure to provide required information may result in your application approval being delayed or your application being returned.

Subject to certain Ohio Revised Code statutory exceptions, most documents and records maintained by the state of Ohio, including those maintained by the Board, 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.

PES 3011 (Rev. 03/2011)

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

Certiicate of Authorization application

3011

Notarized afidavit

STATE OF

AFFiANt

I,[ PRINTED NAME ] ,

being duly sworn, or afirmed, depose and say that I am duly authorized to prepare this application for a Certiicate of Authorization and attest, to the best of my knowledge and belief, that the information contained herein is true.

DECLArAtiON in accordance with section 2909.32 (A)(2)(b) of the Ohio revised Code

For each question, indicate either “yes” or “no” in the space provided. Responses must be truthful to the best of your knowledge.

		YES	NO
1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List?
2.	Have you used any position of prominence you have with any country to persuade others to support an organization	YES	NO
	on the U.S. Department of State Terrorist Exclusion List?
3.	Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State	YES	NO
	Terrorist Exclusion List?
4.	Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist	YES	NO
	Exclusion List?

AFFIANT SIGNATURE

AFFIANT TITLE

DATE SIGNED

PES 3011 (Rev. 03/2011)

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

Firm afidavit of responsibility

3012

Complete a separate Firm afidavit of responsibility for each professional engineer or professional surveyor who is designated in responsible charge. Afidavits of responsibility must accompany all Certiicate of Authorization applications.

Firm name, Ohio Board Certiicate of Authorization number

FIRM NAME >> SAME NAME as on Certiicate of Authorization application OHIO BOARD CERTIFICATE OF AUTHORIZATION NUMBER >> 5-DiGitS

Professional services to be offered by irm

Ohio registrant designated in responsible charge

OHIO P.E., P.S. OR DUAL (P.E. AND P.S.) REGISTRANT DESIGNATED IN RESPONSIBLE CHARGE		P.E. NUMBER		P.S. NUMBER

Notarized afidavit

STATE OF

AFFiANt

I,[ AFFIANT PRINTED NAME ] ,

being the duly sworn, or afirmed, afiant; state that I am a registered professional engineer and/or a registered professional surveyor in the state of Ohio as indicated above; that I am a full time employee of the above-named irm; that I am in responsible charge for and in responsible charge of the professional engineering or professional surveying activities and decisions of this irm; and that I meet the requirements pursuant to Ohio Revised Code Chapter 4733 for such designation.

AFFIANT SIGNATURE

DATE SIGNED

PES 3012 (Rev. 03/2011) 20110301

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