New Jersey Ofce 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
DUPLICATE LICENSE FORM
PLEASE COMPLETE THIS AFFIDAVIT, HAVE IT NOTARIZED AND RETURN IT TO THIS OFFICE, TOGETHER WITH THE
APPROPRIATE FEE. (Please submit a certied check or money order, payable to the State Board of Professional Engineers and Land
Surveyors, in the amount of $20.00. No personal checks will be accepted.)
This is to verify that my license to practice as a Professional Engineer/Professional Land Surveyor for the current renewal cycle has never
been voluntarily surrendered, revoked, or suspended by the State Board of Professional Engineers and Land Surveyors, but has been:
Please check one: LOST DESTROYED MISPLACED STOLEN
NEVER RECEIVED.
Please check license type: Professional Engineer Professional Land Surveyor E-I-T L-I-T
I hereby request that a license be issued for the current renewal cycle.
NAME: _______________________________________________________________________________
LICENSE NO.: _________________________________________________________________________
ADDRESS OF RECORD: _________________________________________________________________
MAILING ADDRESS: ___________________________________________________________________
SOCIAL SECURITY NO.: ________________________________________________________________
DATE OF BIRTH: ______________________________________________________________________
TELEPHONE NO.: _____________________________________________________________________
EMAIL ADDRESS: _____________________________________________________________________
I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE AND CORRECT. I AM AWARE THAT
IF ANY OF THE FOREGOING STATEMENTS MADE BY ME ARE WILFULLY FALSE, I AM SUBJECT TO PUNISHMENT.
SWORN TO BEFORE ME THIS
_________________ DAY OF _________ 20______ ______________________________________
Licensee Signature
___________________________________________
Notary Public
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. 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.
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