Ohio Form Pes 3011 – Fill Out and Use This PDF

OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS	3010
Certiicate of Authorization application instructions

Each application must include…

•Notarized Certiicate of Authorization application: PES 3011.

•Separate notarized Company afidavit of responsibility for each professional engineer and professional surveyor

designated in responsible charge: PES 3012.

•An active Ohio Secretary of State charter or registration number authorizing the company to do business in the state of Ohio. In addition, if a company is using a doing business as (DBA) name, an active Ohio Secretary of State charter or registration number authorizing the company’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, NAME CHANGE, or ADDING DBA 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 otherwise indicated.

•Each full-time employee designated in responsible for, and responsible charge of, the professional engineering or professional surveying activities and decisions must ill out Company afidavit of responsibility PES 3012.

•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 company that holds a Certiicate of Authorization.

•The company 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 company inactive and unauthorized

to practice in the state of Ohio.

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

•Companies 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.

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

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

•Companies 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.

Deliver your completed Certiicate of Authorization application with afidavit(s) and fee to the Board’s address below.

PES 3010 (Rev. 03/2012) 20120307 Page 1 of 1

OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS BOARD USE ONLY	3011
Certiicate of Authorization application

This application is for companies 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.

Application for >> CHOOSE ONLY ONE	$25.00 ANNUAl rENEWAl
$50.00 NEW
$50.00 AddiTiONAl SErviCE	$37.50 lATE ANNUAl rENEWAl

$50.00 NAME CHANgE or AddiNg dBA (doing Business As)

ENTER PREVIOUS COMPANY NAME >>

Ohio Certiicate of Authorization number >> rEQUirEd unless new company professional services to be offered by company

Engineering ONlY

Surveying ONlY

Engineering AND Surveying

Company is registered with the Ohio Secretary of State as

Other DESCRIBE COMPANY TYPE >>

Company contact information >> All fiEldS rEQUirEd UNLESS OTHERWISE INDICATED

An active Ohio Secretary of State (SOS) charter or registration number authorizing the company to do business in the state of Ohio is required for each company name and company DBA name, if used.

OHIO SOS NO.		COMPANY NAME
OHIO SOS NO. >> rEQUirEd with dBA COMPANY DBA >> ONlY if using dBA (doing Business As) name
CONTACT EMAIL ADDRESS					FEDERAL EMPLOYER ID NUMBER
lOCATiON OffEriNg OHiO prOfESSiONAl SErviCES			Indicate if change of address
ADDRESS LINE 1 >> dO NOT USE AgENT AddrESS — pO Box is NOT acceptable					TELEPHONE
ADDRESS LINE 2 >> ONlY if needed					COUNTY >> ONlY if Ohio address
CITY					STATE ZIP+4
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. 03/2012) 20120307

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Ownership If company has more than ive owners, attach additional pages with the same information.

1 COMPANY OWNER NAME		COMPANY OWNER ADDRESS

2 COMPANY OWNER NAME		COMPANY OWNER ADDRESS

3 COMPANY OWNER NAME		COMPANY OWNER ADDRESS

4 COMPANY OWNER NAME		COMPANY OWNER ADDRESS

5 COMPANY OWNER NAME

COMPANY 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 company full time as being responsible for and in responsible charge of the professional engineering or professional surveying activities and decisions of the company.

Name, registration number, position of registrant in responsible charge

iMpOrTANT! Each registrant listed as in responsible charge must include an accompanying Company Afidavit of respon- sibility (PES 3012). If more than four registrants are in responsible charge, attach additional pages with the same information.

1 PRINTED NAME >> include notarized pES 3012

iNdiCATE All THAT ApplY

2 PRINTED NAME >> include notarized pES 3012

iNdiCATE All THAT ApplY

3 PRINTED NAME >> include notarized pES 3012

iNdiCATE All THAT ApplY

4 PRINTED NAME >> include notarized pES 3012

iNdiCATE All THAT ApplY

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Additional Ohio p.E., p.S. registrants employed by company

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

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

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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.

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.

PES 3011 (Rev. 03/2012) 20120307 Page 4 of 4

COMPANY NAME >> SAME NAME as on Certiicate of Authorization application	OHIO CERTIFICATE OF AUTHORIZATION NUMBER >> 5-DIGItS

Professional services to be offered by company

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 company; that I am in responsible charge for and in responsible charge of the professional engineering or professional surveying activities and decisions of this company; and that I meet the requirements pursuant to Ohio Revised Code Chapter 4733 for such designation.

Deliver your completed Company afidavit of responsibility to the Board’s address below.

PES 3012 (Rev. 03/2012) 20120307 Page 1 of 1