Ohio Form 4011 D PDF Details

In a move that underscores its commitment to maintaining high standards within the professional engineering and surveying community in Ohio, the State Board of Registration for Professional Engineers and Surveyors has issued the 4011-D form for the 2012-2013 license renewal period. This pivotal document serves as a reminder to professionals holding dual P.E. (Professional Engineer) and P.S. (Professional Surveyor) licenses of the mandatory renewal process. A remarkable aspect of this process is the option to renew online, a facility that significantly streamlines the procedure. The form stipulates a clear deadline for renewal, highlighting the increase in renewal fees post-December 31, 2011, and emphasizing the necessity of adhering to continuing professional development (CPD) requirements as outlined in section 4733.151 of the Ohio Revised Code. Importantly, the form also serves as a tool for updating personal details, including any changes in name and address, with the provision that any name changes must be substantiated with legal documentation. Equally crucial is the form’s role in ensuring transparency regarding the professional conduct of license holders, requiring disclosures about any convictions or actions taken against their registration, thus maintaining the integrity of the profession. However, it is noteworthy that the 4011-D form cannot be used for license reinstatement, indicating a clear procedural boundary. The emphasis on completing the CPD requirements and the stark reminder that failure to comply may result in the inability to renew underscores the Board's commitment to ongoing professional development within its community.

QuestionAnswer
Form NameOhio Form 4011 D
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names4011 D 20111020 fill in B pepsohiogov form

Form Preview Example

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

4011-D

2012-2013 Ohio Dual P.e., P.S. License

 

renewal Application

 

reMINDer! For faster license renewal, renew online at www.peps.ohio.gov.

DO NOt SUBMIt application if continuing professional development require- ments are not complete in accordance with section 4733.151 of the Ohio R.C.

NAMe AND ADDreSS reQUIreD

NAME

 

 

P.e. AND P.S. NUMBerS reQUIreD

 

 

 

PE–

 

 

PS–

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$80.00 DUe NOW

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

AMOUNT DUE After 12/31/2011: $120.00

CITY

STATE ZIP CODE

Make your check or money order payable in U.S.

 

 

 

 

 

 

funds to treasurer, State of Ohio.

 

 

 

►

NAMe cHANGe AND/Or cHANGe Of ADDreSS ONLy

NAME CHANGE reQUIreS LeGAL DOcUMeNtAtION

ADDRESS

ADDRESS

CITY

STATE

ZIP CODE

 

 

 

OHIO COUNTY reQUIreD If OHIO ADDreSS

I do not plan to renew at this time.

IMPOrtANt — DO NOt USe tHIS

fOrM fOr reINStAteMeNt!

this application cANNOt be used for reinstatement of a professional license. It is to be used for 2012-2013

P.E., P.S. renewals only. Email the Board, at pes.board@ pes.ohio.gov, for reinstatement instructions.

DO NOt SUBMIt copies of continuing professional development information with this application.

yeS NO I certify that I have completed 15 continuing professional development hours in accordance with section 4733.151

of the Ohio Revised Code –Or– I’m exempt from this requirement because I was granted initial registration during calendar year 2011.

If you answered NO to this question, DO NOt submit this renewal application.

FOR MORE INFORMATION REGARDING THE CPD REQUIREMENT, CPD AUDIT, AND DOWNLOADING CPD ACTIVITY LOGS, VISIT OUR WEBSITE AT www.peps.ohio.gov.

yeS NO Since your last renewal have you been convicted of or pleaded guilty to any felony or crime involving moral turpitude or had your registration revoked, voluntarily surrendered or suspended by another jurisdiction? If yeS, please give date, type of conviction, court of conviction, case number, and explanation.

ATTACH SEPARATE SHEET IF NEEDED

►

I certIfy that this is a properly completed and accurate license renewal application which I am submitting to the state of Ohio’s State Board of Registration for Professional Engineers and Surveyors. I have not omitted any requested information. I

understand that my renewal is contingent upon satisfactory completion of all requirements. I further understand that any person who knowingly makes false statements on the renewal application is guilty of falsiication under section 4733.20 of the Ohio

Revised Code, and subject to penalties under law.

Applicant Signature

2012-2013 DUAL Pe PS LIceNSe reNeWAL

STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS

50 W BROAD ST STE 1820 COLUMBUS OH 43215-5905

Date Signed

Make check or money order payable in U.S. funds to treasurer, State of Ohio. Cash is not accepted. for credit card payment, renew online. Send completed, signed, and dated application and fee; postmarked no later than 12/31/2011; to the Board address at left.

PES 4011-D (Rev. 10/2011) 1020

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