Fillable Application for Licensure as a Professional Land Surveyor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for Licensure as a Professional Land Surveyor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers
and Land Surveyors
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Instructions for Completing an
Application for Licensure as a Professional Land Surveyor
Please read the following information carefully before completing an application for licensure as a Professional Land Surveyor.
If you previously held a Professional Land Surveyor’s license in New Jersey, DO NOT complete this application. You must complete
an application for reinstatement/reactivation.
Please do not submit this application until you have passed the Fundamentals of Land Surveying (FS) and the Principles
and Practices of Land Surveying (PS) examinations and have obtained three (3) full years of professional surveying experience.
You may take the FS and PS exams without obtaining prior Board approval.
Please visit the Board’s website at www.njconsumeraffairs.gov/pels/Pages/default.aspx for information concerning licensing requirements.
The Board will accept transcripts, license verications, and examination results submitted directly to the Board from an educational
institution or professional board, or through NCEES. An NCEES record does not substitute for this application.
1. Complete an application for licensure as a professional land surveyor. Answer ALL of the questions.
2. Sign the application in the presence of a notary public (Page 8). Your application must be notarized or it will be returned to you
which will delay the process.
3. Attach a clear, full-face original color passport-style photograph (2” x 2”) of your head and shoulders taken within the past six
months. (Photocopies and seles are not acceptable.)
4. Arrange for your undergraduate/graduate transcripts to be sent directly to the Board. If you have an undergraduate degree from
a non-ABET accredited program, please have your education credentials evaluated by one of the Board’s recommended
providers. (See the Board’s website for information.)
5. Submit proof of passing the FS and the PS examinations.
6. Complete the Report of Professional Experience on the Board-approved form attached to the application. The Board will not
accept any other form. The Board requires three (3) full years of professional surveying experience, two of which must have
been gained in the U.S.
7. Complete the Detailed Breakdown of Surveying Experience on the form included with the application.
8. Submit ve (5) references, unrelated to you, on the Board-approved form. Three (3) of the ve references must be licensed
professional land surveyors in the United States, have personal knowledge of your practice and attest whether you are qualied
to be placed in responsible charge. At least one of the references must be from a supervisor who has knowledge of four (4) years
of your experience, two years of which must be in engineering design.
9. Ifyouareapplyingbycomity,providewrittenvericationoflicensureingoodstandingfromallstatesinwhichyouarelicensed.
10. Ifyouarealegalalienorotherimmigrationstatus,pleasesubmityourUSCISimmigrationdocuments.(Submitacopyofboth
thefrontandthebackofyourcard.)
11.Submitcriminalhistorydocuments(ifapplicable).
12.Submitcopiesofalldisciplinaryactionstakenagainstyourprofessionallandsurveyor’slicense(s)inanyotherjurisdiction(if
applicable).
13. Pleasesubmitanonrefundableapplicationfeeintheformofacheckormoneyorder,payabletotheStateofNewJersey,inthe
amountof$75.00.
14.OnceyourapplicationhasbeenfullyapprovedbytheBoard,youwillreceiveaLicenseActivationForm.Pleasecompletethis
formandsubmitalicensefeeintheformofacheckormoneyorder,payabletotheStateofNewJersey,intheamountstated
ontheLicenseActivationForm.
Please submit all of the above-referenced documents to:
New Jersey State Board of Professional Engineers and Land Surveyors
124HalseyStreet,3rdFloor
P.O.Box45015
Newark,NewJersey07101
Application
number _______________________
Date _________________ , ________
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers
and Land Surveyors
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Professional Land Surveyor Application
A nonrefundable application ling fee of $75, in the form of a check or money order made payable to the State of New Jersey, must be
submitted with this application. (Applicants should understand that if the application ling fee is paid with a personal check, and the
check is returned by the bank due to insufcient funds, the next step in the licensure or certication process will be delayed until the fee
is paid.) Please see Fee Schedule for license fee at: www.njconsumeraffairs.gov/pel/Applications/Fee-Schedule.pdf.
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application (including your address of record) may be subject to public disclosure as required by
the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
Mr.
1. Name Mrs. __________________________________________________________ ( _____________________ )
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: _____________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_________________________________ _______________________________
Telephone number (include area code) E-mail address
Business: __________________________________________________________________________________
Name of company Telephone number (include area code)
___________________________________________________________________________________
Street City State ZIP code County
Mailing: ___________________________________________________________________________________
Street or P.O. Box City State ZIP code County
NCEES Record Number (if applicable): _______________________________
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photo is required with each
application.
Do not use a paper clip to attach
the photo.
- 1 -
Rev. 10/12/17
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et. seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records; and
b. the Probation Division or any other agency responsible for child-support enforcement, upon request.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
- 2 -
click to sign
signature
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- 3 -
6. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
7. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete explanation.
(Attach additional sheets of paper to this application.)
8. Do you currently hold, or have you ever held, a professional or occupational license or certicate (i.e. radon measurement
technician or specialist, radon mitigation technician or specialist, etc.) of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction, other than professional land surveyor? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please proivde that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. Have you ever been disciplined or denied a professional license or certicate or any other professional license or certicate in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
10. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
11. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever been named as a defendant in any litigation related to the practice of professional land surveying or other professional
practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
15. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of professional land surveying or other professional practice in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 9 through 15, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
- 4 -
16. Land Surveyor-in-Training
Do you currently hold a New Jersey Land Surveyor-in-Training certicate? Yes No
If “Yes,” please provide the certicate number and the date issued. _________________________________________
Do you currently hold a Land-Surveyor-in-Training certicate from another state or jurisdiction?
Yes No
If “Yes,” please provide the state, certicate number and the date issued.
17. ProfeSSionaL Land Surveyor’S examinaTionS
Have you passed any portion of the land surveyor’s examination in any state or jurisdiction? Yes No
18. ProfeSSionaL Land Surveyor’S LicenceS (for comiTy aPPLicanTS onLy)
Do you currently hold, or have you ever held a professional land surveyor’s license in New Jersey or any
other state or jurisdiction, including the District of Columbia?
Yes No
If “Yes,” please provide the relevant information below:
Do you currently have on le, or have you ever led, an application to become a professional land surveyor in New
Jersey?
Yes No
If “Yes,” please provide the application number. _________________________________________
Date Issued
Certicate Number
State
Fundamentals of Land
Surveying Examination
Principles and Practices of
Land Surveying Examination
Date of Exam
Number of hours
Exam
State
State Specic
Received license through:
State or
jurisdiction that
issued the license
Type of license
or certicate
License number
Date
issued/expired
Oral or written
examination
Grandfathering
Endorsement/
Comity/
Reciprocity
Examination
- 5 -
19. Education*
(Fill out completely–do not refer to other forms, etc.)
BachElor’sdEgrEEinlandsurvEying
______________________________________________________________________________________
Name and Location of Institution Full-Time/Part-Time Years (From/To) Date Graduated Curriculum Degree Received
______________________________________________________________________________________
Name and Location of Institution Full-Time/Part-Time Years (From/To) Date Graduated Curriculum Degree Received
______________________________________________________________________________________
Name and Location of Institution Full-Time/Part-Time Years (From/To) Date Graduated Curriculum Degree Received
graduatEdEgrEEinlandsurvEying
______________________________________________________________________________________
Name and Location of Institution Full-Time/Part-Time Years (From/To) Date Graduated Curriculum Degree Received
______________________________________________________________________________________
Name and Location of Institution Full-Time/Part-Time Years (From/To) Date Graduated Curriculum Degree Received
______________________________________________________________________________________
Name and Location of Institution Full-Time/Part-Time Years (From/To) Date Graduated Curriculum Degree Received
* An ofcial transcript must be submitted to the Board ofce directly from the institution. This requirement also
applies to applicants educated in a foreign country.
Name Address
Licensed in
the state of:
Familiar with work
in engagement
(See RPE on page 6. )
Engagement number
License
Number
20. rEfErEncEsofcharactErandqualifications
Give the name and address of ve references, none of whom is related to you. Three of these references must hold a valid United
States professional engineer’s license and have personal knowledge of the applicant’s practice. At least one of the references must
be from a supervisor who has knowledge of four (4) years of your experience, two years of which must be in engineering design.
No member of the Board will be accepted as a reference. The applicant must download and distribute one form to each
individual listed as a reference. Click on the link www.njconsumeraffairs.gov/pels/Applications/Land-Surveyor-Reference-
Form.pdf for the reference form. The signature of each person used as a reference is not required below.
Engagement number
Engagement number
Engagement number
Engagement number
- 6 -
Report of Professional Experience (RPE)
For _________________________________by_____________________________________ Date __________________
Print Name Signature
(1)
Engagement
Number
(2)
Date
Month/Year
From-To
(3)
Description of
Experience
(4)
Surveying
Experience in
Years and Tenths
(5)
Total Time
Time This page
ToTaLS Cumulative
total
ToTaLS on TheSe PageS
muST Be The Same.
- 7 -
Detailed Breakdown of Surveying Experience
Property-Line Experience
Field Work
Rod Person
Instrument Person
Party Chief
Supervision
Record Research
Ofce
Note Reduction
Subdivision Design
Property-line calculations
Plotting and Drafting
Descriptions
Supervision
Other than property-line experience
Horizontal and Vertical
Control for photo
Computation
Construction layout
Geodetic work
Control Surveys
Topographic Surveys
Other
Time
years & tenths
Time This page
ToTaLS
ToTaLS on TheSe
PageS muST Be The Same.
affidaviT
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the State Board of Professional
Engineers and Land Surveyors for licensure or certication under the provisions of Title 45 of the General Statutes of New
Jersey and the Rules of the State Board of Professional Engineers and Land Surveyors, swear (or afrm) that I am the
applicant and that all information provided in connection with this application is true to the best of my knowledge and belief.
I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny licensure
or certication or to withhold renewal of or suspend or revoke a license or certicate issued by the Board.
I swear (or afrm) that I have read N.J.S.A. 45:8-27 et seq., together with the Rules and Regulations of the State Board of
Professional Engineers and Land Surveyors, N.J.A.C. 13:40-1.1 through 13:40-13.9, and fully understand that in receiving
licensure or certication from the Board, I bind myself to be governed by them.
I further swear (or afrm) that, pursuant to N.J.S.A. 45:8-35, I am able to speak and write English language.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for the
purpose of verifying my qualications for licensure or certication. I further authorize all institutions, employers, agencies
and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or
records requested by the Board.
_____________________________________________
Applicant’s signature
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Afx Seal Here
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
- 8 -
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Application for Licensure as a Professional Land Surveyor (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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