Fillable Certicate of Authorization Reinstatement Instruction Sheet New Jersey (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Certicate of Authorization Reinstatement Instruction Sheet New Jersey (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

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Certicate of Authorization Reinstatement Instruction Sheet
The application must be typed or printed clearly. Separate sheets of paper may be used for additional
information.
Please submit the following:
• A nonrefundable reinstatement fee of $125.00, made payable to the State Board of Professional
Engineers and Land Surveyors.
• A fee of $120.00 for the two-year biennial cycle for which reinstatement is sought, made payable
to the State Board of Professional Engineers and Land Surveyors.
• The “Details of Ownership” information must be submitted with the reinstatement application.
• A copy of the most current annual report led with Division of Revenue in the New Jersey
Department of Treasury.
Any changes (corporate address, address of record, if different, professional engineer and/or land
surveyor in responsible charge, corporate ofcers, etc.) must be reported in writing within 30 days
of the change.
• Return the Certicate of Authorization reinstatement application to the address below.
STATE BOARD OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS
P.O. BOX 45015
NEWARK, NJ 07101
NOTE: Applications not signed, notarized, dated or received without required documentation will
be returned.
PLEASE INDICATE A DESIGNATED RESPONSIBLE-CHARGE LICENSEE AS THE CONTACT
PERSON WHO WILL RECEIVE ALL CORRESPONDENCE FROM THE BOARD.
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
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
Reinstatement Application for a Certicate of Authorization
Required pursuant to the provisions of N.J.A.C, 13:40-10.2(e)
Period from: ____________________ Period to: _________________ Certicate No.: ______________________________
Reinstatement fee: $125.00 - Make your check or money order payable to the State Board of Professional Engineers and Land Surveyors
and return to: State Board of Professional Engineers and Land Surveyors, P.O. Box 45015, Newark, NJ 07101.
Business name Telephone no. (include area code)
Business address
Complete this section only if your name or address is different from that printed above.
(You must include a copy of legal documentation for a name change.)
Business name Telephone no. (include area code)
Business address
Print name of licensee in responsible charge
Please submit a copy of the current annual report led with the Division of Revenue in the New Jersey Department of the
Treasury with this application.
Certication Statement
“I certify that the information entered on this form is true and complete to the best of my knowledge, and further acknowledge
that if the above information is willfully false, I am subject to punishment and/or disciplinary sanction including license or
certication suspension/revocation or the imposition of civil penalties as may be provided by law.”
Signature of licensee in responsible charge Date
Print name of licensee in responsible charge Business telephone no. (include area code)
Print full license number of licensee in responsible charge E-mail address
If the name of the licensee in responsible charge has changed, check this box to receive a new wall certicate.
Details of ownership
Professional Engineers Land Surveyors Professional Engineers
and Land Surveyors
Please check if there have been no changes to the Details of Ownership since originally led.
Designation:* D = Director M = Manager or Member O = Ofcer
P = Principal Stockholder A = All designations
Please specify if more than one designation is applicable.
Name and address (and title if any)
of each ofcer, director, manager D M O
and principal stockholders. P A Owned Percent New Jersey license number, if applicable Signature
Use an additional sheet of paper if necessary.
Total shares issued Issued: ____________________
and outstanding. Outstanding: _______________
I certify that I am familiar with the
laws and regulations governing the
practices of professional engineers
and/or land surveyors in New Jersey.
I am aware that the Certificate of
Authorization may be revoked if any
agent, employee, director or ofcer of
the corporation or manager or member
of a limited liability company violates
or causes to be violated any provisions
of those laws or regulations.
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
In accordance with N.J.A.C. 13:27-4.8(d), the L.L.C. or corporation and its
licensees have a continuing duty to inform the Board within 30 days of any
change in the information that was originally provided to the Board.
_________________________________________________
Signature of licensee in-responsible-charge
Rev. 1/17
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
PE _________________ ID ________________
RA _________________ PP ________________
LS _________________ LA ________________
*Desig. Number of shares
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Certicate of Authorization Reinstatement Instruction Sheet New Jersey (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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