Fill - Free fillable Ls-reinstatement Updated (Commonwealth of Massachusetts) PDF form

Massachusetts Board of Registration of Professional Engineers and Professional Land Surveyors

PLS Reinstatement Application Cover Sheet

All applicants must submit the following items along with the completed application form to DPL:

Check or money order in the amount of $216.00 made payable to “Commonwealth of Massachusetts”

(additional fees will be assessed upon approval of the reinstatement)

(licensure/certification fees will be assessed when all other requirements are met)

Documentation of experience, e.g. drawings, calculations, field notes, etc. from the earliest date of being registered in

Massachusetts to the present time.

(See application instructions for specifics on what can and cannot be submitted)

Social Security Number:

(Pursuant to MGL C62C, §47A, the Division of Professional Licensure is required to obtain your social security number and forward it to the

Department of Revenue. The Department of Revenue will use your social security number to ascertain whether you are in compliance with

the tax laws of the Commonwealth)

Applicants must also have the following items transmitted directly to DPL under separate cover:

Transcripts mailed directly to Division of Professional Licensure (DPL) in a sealed envelope from each college or university that

the applicant has attended since having been originally registered in Massachusetts.

A “Request for Verification” form sent directly to the Division of Professional Licensure (DPL) from each non-Massachusetts

jurisdiction (other than Massachusetts) in which the applicant has taken the NCEES sanctioned Fundamentals Exam or Principles

and Practices Exam. (See application instructions)

Please send this page and the completed application form to:

Division of Professional Licensure

Board of Engineers and Land Surveyors

1000 Washington Street, Suite 710 ● Boston, MA 02118

Page 1 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION INSTRUCTIONS

www.mass.gov/dpl/boards/en

AUTHORITY: You are requ ired to provide al l the

information requested in the application forms per MGL

C112, §81 and 250 CMR . It is the responsibility of the

applicant to have read and u nderstood the provisions of

these laws, rul es, and reg ulations and the instructions

contained herein, before making application.

F

ORMS: The application is comprised of four separate

sections, the application form itself, the instruction

sheets, Attachment A a nd the Experience Table

Narrative Cover Sheet. Except for the i nstructions, each

must be completed and transmitted to the Board as set

forth herein. Provide information only in those spaces

indicated on the forms. Do not rearrange or al ter this

form in any way. Applications will be rejected and

application fees forfeited if any portion of this form is

altered. If add itional space is required, make reference

to a numbered addendum and title the top of the

addendum “Attachment #__”.

O

RAL EXAMINATIONS: Applicants may be required to

submit to an oral examination or interview and to

submit experience documentation. The oral examination

may address a number of i ssues, including: quality of

experience, responsible charge time, knowledge of

surveying principles, familiarity with common practices,

etc. The app licant should bring to the i nterview, copies

of research notes, field notes, calculations, work sheets,

plans, etc. covering several jobs that demonstrate

knowledge and skills associated with a variety of land

surveying projects as indicated in section 26. There is no

fee for oral examinations.

R

ULES & REGULATIONS: All applicants are required to have

obtained and to understand the provisions of 250 CMR

(code of Massachusetts Regulations) prior to completing

this application. Copies are avai lable by calling (617)

727-2834 or by accessing the Commonwealth’s web

page at

http://www.sec.state.ma.us/spr/sprcat/catidx.htm.

NON–RESIDENTS: Applicants that do n ot reside in

Massachusetts or whose pr imary place of practice is in

another state are subject to the same requirements as

Massachusetts applicants and licensees. Each is required

to have a thorough knowledge of t he laws, rules and

regulations affecting the practice of land sur veying in

the Commonwealth of Massachusetts.

F

ALSE STATEMENTS: Massachusetts Law provides that

applications containing false statements must be

rejected regardless of the other qualifications of the

applicant.

INSTRUCTIONS

All information appearing on this form must be

typewritten or printed. Applications materials must be

transmitted via postal mail to the Board. Application s

will not be processed if any part of this form is

incomplete. Applications will be rejected and application

fees forfeited if any portion of this form is altered.

Section 1: Fill in your name as it appears on your

birth certificate and appear ing with your socia l security

number. This should be the same name as appears o n

other registrations/licenses for Massachusetts or in other

jurisdictions. IF you ar e known by an alias, an swer yes

to section 16 and supply the information requested.

Section 2: Provide any other name(s) by which yo u

may have been known such as a m aiden name. (see

also section 16)

Section 3: Provide your current residential address and

P.O. Box if applicable.

Section 4: Provide the company name and address o f

your current employer.

Section 5: Specify where you would like correspondence

regarding your application directed.

Section 6: Provide your date of birth.

Section 7: Provide your place of birth, City, State, Zip.

Section 8: Declare your citizenship. If other than the

United States, then specify.

Section 9: Provide a day time and evening telephone

number where you can be r eached during the proc essing

of the application.

Section 10: to Section 18: Check the correct response

for each of th ese background questions. If the an swer to

any question is YES, then you mu st provide the Board

with a brief narrative describing the specifics. “Attachment

A” has one box for each of these sections if needed.

Section 19: Specify the jurisdiction (state), the date and

if you pa ssed, failed or w ere disqualified for each NCEES

Fundamentals of Land S urveying you have taken. If the

exam was not taken in Massachusetts, the enclosed

“Request for Verification” form must be for warded to each

of the jurisdictions in which you have taken the

fundamentals examination and returned by the jurisdiction

directly to the Board.

Section 20: Specify the state/jurisdiction, most recent

date exam was tak en, number of times exam was tak en

(indicate n/a if passed), hours of t he exam and if yo u

passed, failed or were di squalified for each NCEES

Principles & Practices of La nd Surveying exam you have

taken. Foreign applicants who have tak en and passed

other qualification exams in jurisdictions other than the

US should provide such information in a supplemental

format as an attachment. If the ex am was not taken in

Massachusetts, the enclosed “Request for Verification”

form must be forwarded to the jurisdiction in which you

have taken the principles and practices ex amination and

returned by that jurisdiction directly to the Board.

Section 21: Specify the most recent date exam was

taken, number of times exam was taken (indicate n/a if

passed), hours of exam a nd if you passed, failed or wer e

disqualified for each Massachusetts State-Specific

Jurisprudence Land Surveying exam you have taken.

Section 22: Indicate the profession al organizations of

which you are curren tly a memb er. List only those

organizations that are rela ted to the pro fession of land

surveying.

Section 23: Use this section to list all of your academic

background. If you have not earned a college, university

or technical school degree, t hen your high s chool data

must be provided. Do not list courses of study that were

not accredited by an a cademic institution. These might

include short courses, civil service or armed forces schools

or similar training, workshops, seminars, etc.

List, chronologically the name and address of each

college, university, or technical school attended, the dates

of such attendance and the curriculum. If a graduate, list

the degree obtained or otherwise list the number of credit

hours earned. Graduate wor k, evening school, and oth er

education for whic h academic credit is given must be

included in the list.

Transcripts are required by the Board fo r each of t he

schools that were attended after the date of your original

Page 2 of 17

Updated 10/09/2015

GENERAL INFORMATION

PLS REINSTATEMENT APPLICATION INSTRUCTIONS

registration in Ma ssachusetts (the remainder of the

transcripts are available from your original application).

Applicants must not submit transcripts directly to the

Board, as these must be received directly from the

schools. However, it is the applicant’s responsibility to

insure that the Board receives the transcript from the

school.

Section 24: Use this section to list all non-academic or

other non–degree academic courses of stud ies

completed. This list should include any course,

workshop, seminar, etc. which would demonstrate some

additional competency in the disciplines of land

surveying. Applicant should provide the Board with

certificates of completion or other evidence that such

courses of study were successfully completed.

Section 25: Use this section to indicate other

independent programs of study that w ould provide

evidence of your qualification s as a la nd surveyor, bu t

that do not fit i nto the previous sections. Use this

section to include self study programs, class audits, etc.

Indicate the letter designation of the a ttachment, which

describes the program of study. This should be a brief

written narrative detailing the time commitment

involved, texts, objectives, and date of study.

Section 26: Use the experience table to list, in

chronological order, your employment history since the

time of your ori ginal registration in Massachusetts (do

not list experience that appeared on your original

application for registration). The per iod during which

your licensed had lapsed must be clearly identified in the

table along with the type of activities performed during

that period. If additiona l entries will be n ecessary, they

must be supplied as an addendum in the same format.

Engagement number one should reflect your mos t

current employment experience. Work backwards from

engagement number one to the date you were originally

registered to practice in Massachusetts. No record is to

be made for work done be fore the applicant became

registered. Table entries should cover periods of

employment of a particular nature. If the nature of your

position, hence the type of experience, within an

employment period changes significantly, use a new key

in the table to indicate such experience.

Employment that was not directly related to land

surveying must also be included in order to leave no

gaps in the complete chronological listing. However, if a

number of co ntiguous engagements were unrelated to

engineering/land surveying, you may group them

together and designate that period as such. Per iods of

unemployment, or oth er gaps should be noted rather

than leaving a period of time without explanation. If part

of the chronological experience record includes time

spent in military service, the applicant should furnish a

completely legible copy of the “R eport of Separation

from the Armed Forces of the United States of America”

as was issued upon discharge. This may be a DD-214 or

a WD-AGO Government Form.

Supply one copy of the accompa nying addendum

entitled “Experience Engagement Coversheet” for each

engagement in the experience table and attach it to the

reference materials being submitted for that

engagement period. Additional copies of this form may

be made a s required. Provide a brief narrative for ea ch

section of the cover she et addressing the referenced

matters pertinent for that employment period.

Typical duties refer to your specific job functions in the

company or firm and the approximate time commitment

that accrued to each fun ction you regul arly performed.

Scope of experience refers to the types of land surveying

projects with which you were typically involved and the

approximate percentage of time that accrued to each.

Your level of respon sibility should detail to what ex tent

you were entrusted to work independently or conver sely

the amount of supervision you typically received for

specific engagements. Include under scope of experience,

the type of responsible charge experience that was

involved.

The company profile should indicate first the

multidisciplinary services offered by the employer for that

engagement and second the primary types of la nd

surveying services it offers. For multidisciplinary firms,

indicate the types of services offered (i.e. land surveying,

engineering, architecture, geodesy, photogrammetry,

construction layout, etc.) and appro ximately what

percentage of time each comprises of the company’s total

workload (for instance engineering 40%, land surveying

35%, Landscaping 25%). Indicate the primary types of

land surveying services the company typically offers such

as topography, retracement, permitting, subdivision,

mortgage, layout, control, geodetic, right of way, etc. and

approximately what percentag e of the co mpany’s

commitment to land surveying each comprises.

Care must be taken not to c laim land surveying

experience, which is a ctually part of ot her professional

disciplines. For experience keys that claim responsible

charge time, provide sufficient details to distingu ish that

experience as such (see definition for responsible charge).

In describing your experience, use specific terms, such as:

“I designed”, “I reviewed”, “I recommended”, etc. Avoid

vague terms, such as: involved with, participated in, etc.

For each enga gement period, that covers land surveying

experience, supplemental information MUST BE

FURNISHED and attached to the appropriate cover sheet

for that enga gement number. Supplemental information

should reflect work actually performed by you or u nder

your direction of land surveying projects. It should include

copies of r esearch notes, field notes, calculations, work

sheets, final plans, and reports made by you or u nder

your direction. All supplemental materials should be

provided on letter size (8 ½” by 11”) sheets. For copies of

bound notebooks, or o ther fixed size documents,

photographic enlargement/reduction to letter size is

acceptable. Larger documents that would be unreadable if

reduced, should be folded to letter size. The supplemental

information package total weight should not exceed one

pound. Select representative materials within this limit.

Supplemental information becomes the property of th e

Board and will not be returned.

Select supplemental materials that present a

representative picture of the progression of yo ur

responsibilities and exp erience over the breadth of your

employment for each e ngagement. Supply examples of

work performed ex clusively by you o r under your

direction. If you were th e co-author of a docu ment that is

important to your experience record, then circle the part

which you p ersonally prepared or add a hand writ ten

explanation thereon describing your contribution, for

example: “I supervised the reconnaissance/evidence

reconciliation for this project”, or “I performed the

technical/investigative research for this work”, etc. Do not

include bound sets of sp ecifications or co ntract drawings,

for which y ou were only marginally involved. Focus on

quality, not quantity.

Column (a) Engagement Number: Enter the number of

the engagement, beg inning with number 1 as the

Page 3 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION INSTRUCTIONS

most recent work and increasing by o ne for each

row of the tabl e. Electronic forms may already be

numbered. Each engagement should address a

particular phase of your experience history. It is not

unusual to li st more than one engagement for a

single employer or academic institution.

Column (b) Experience Categories: Choose one of the

following three letter acronyms to represent the

most appropriate exp erience designation for each

engagement.

OWN Owner: of the busi ness or a n officer of the

corporation, board member, etc.

MNG Manager: of business operations.

ADM Administrator: Either supervises and plans

the administration of land surveying services

for a project or is assigned to provide the

lead services for a proj ect. The latter refers

to an individual who is assigned to provide all

or most of the contracting, research,

reconnaissance, fieldwork, analysis, and

documentation for a particular land surveying

project.

ANL Analyst: Evaluates and reconciles record

versus physical evidence via law of evidence

and state regulation. One who is skilled in the

mathematical treatment of such data and the

processing of such dat a by use of comp uter

applications.

INV Investigator (reconnaissance, research,

compile, directs, etc.)

CHF Party Chief (one or many parties)

RES Researcher of records at the registry of

deeds, probate court, highway department,

etc.

PRO Post Processor of field m easurements, deed

closures, map checks, etc. but not yet skilled

as an Analyst)

CAD Computer Assisted Drafting person.

INS Instrument Person on a field party.

ROD Rod Person on a field party/

TRA Training or apprentice type activities.

OTH Other activities unrelated to Land Surveying

Column (c) Fill in the beginning date in the forma t

“month/year” for each en gagement number. This

should not overlap or be the same as any other

ending date.

Column (d) Fill in the ending date in the fo rmat

“month/year” for each en gagement number. This

should not overlap or be the same as any other

beginning date.

Column (e) Using the beginning and ending dates for

each engagement number, compute the elapsed

time in years and enter that amount in this column.

Round all entries to the nearest tenth of a y ear for

columns (e) thru (j).

Column (f) For each engagement number, determine

what portion of (e) is attributable to land surveying

experience obtained while training for a posi tion or

prior to being put in a resp onsible charge at tha t

position. This column should include time for each

change of position for an employer, even if it follows

a period when you were in responsible charge for a

previous position, such as moving from party chief

to working in a new offi ce position. Do no t assume

that because you achieved a re sponsible charge

position for one duty, that from tha t time forward

all of your time will be considered by the Board to be

in responsible charge.

Column (g) For each engagement number, determine

what portion of (e) is attributable to land surveying

experience in responsible charge and enter tha t

amount in this column. For an explanation of the term

“Responsible Charge” as used in this context, refer to

the Glossary.

Column (h) For each engagement number, determine

what portion of (e) is attributable to experience while

holding a valid registration to practice Land Surveying

in another state or jurisdiction and enter that amount

in this column.

Column (i) For each engagement number, determine

what portion of (e) is attributable to just land

surveying experience as def ined by the registration

law (MGL C112, §81D). The time in this column

should equal the total of columns ( f) thorough (h).

Experience that does not comply with MGL’s definition

of land s urveying should be listed in column (j).

Entries in th is column must not overlap experience

time appearing on o ther professional licensing

application, regardless of ju risdiction, for licensure in

disciplines other than land surveying. Therefore, if

you have claimed a period of engineering experience

on another application form for li censure, you must

list that period as such and it must not be included as

experience in columns (f) through (h).

Column (j) Enter the time in this column associated with

academic engagements as noted in section 24 or any

employment experience that that does not comply

with the definition of land surveying as defined by the

registration law, MGL C112, §81D.

Column (k) For each engagement number, provide the

name of t he supervising Land Surveyor who was i n

“responsible charge” of your land surveying work for

that time period. Include that supervisor’s license

number, jurisdiction, current daytime telephone

number and employer at the time of that engagement

number. Note: “independent contractors” and

“employees” are hired on a very different contractual

basis and hence have very different “direct charge”

and supervisory roles with regard to the employees of

the contracting firm that is actually providing the

client service. For the Board to properly evalua te

experience under MGL c 112, you m ust never

designate the employer of an “independent

contractor” or “sub-contractor” as being the

contracting firm. If the supervisor for an engagement

period is deceased, so indicate and provide the name

of another senior member of the fi rm (preferably a

land surveyor) who ca n verify your e mployment

experience.

Column (l) Provide the n ame, address, and telephon e

number of the place where you were employed for

each engagement. The word “same” can be entered if

there was no c hange from the previous (listed above)

employer. If the firm has dissolved or if it is now

operating under a different name, such details must

be provided. If the fir m has dissolved, provide the

name of a ref erence (preferably a professi onal land

surveyor) that can verify the employment experience

for that period. If you were self-employed, you must

provide the name of an associate or client, preferably

a registered Professional Land Surveyor, to verify

your employment status for that period.

Page 4 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION INSTRUCTIONS

GLOSSARY

ACADEMIC: Of, re lating to, or characteristic of an

institution or scholarly establishment of higher learning

offering accredited courses beyond the grade of high

school.

A

CADEMIC DEGREE: title granted by a college or university,

usually signifying completion of an established course of

study.

A

DDENDUM: When there is insufficient space provided for

required information, an ad dendum should be attach ed

and a ref erence to it supplied in the space for the

applicant’s response. Addenda should be 8.5 by 11 in ch

sheets entitled “Attachment #__” on the top center of

the sheet. Use one sheet for each attachment.

A

PPLICANT: The person ma king this application and

attesting to the truthfulness of the statements and facts

contained herein.

A

PPROVED COURSES: Land surveying courses approved by

the Board or comprising one of the core subjects for an

academic curriculum in land surveying.

B

OARD: The Commonwealth of Massa chusetts Board of

Registration of Professi onal Engineers and Professional

Land Surveyors. Sometimes used to refer to the

collective authority of all such Boards of regi stration for

engineers and land surveyors.

C

LIENT: A person for whom the practitioner is performing

services. A client may be a property owner, co ntractor,

developer, etc.

CMR: Code of Massachusetts Regulations

COMITY: In the context used by t he Board, is the

principle by which one jurisdiction may accede or give

effect to the l aws or j udgments of a nother Board.

Massachusetts grants comity consideration only if the

Board can determine that licensee’s primary jurisdiction

licensed the applicant in compliance with Massachusetts

requirements. In th e case of a person appl ying for

registration as a land surveyor, the applicant will always

be required to take and pa ss the Massachusetts specific

examination.

D

IRECT CHARGE: See Direct Supervision

DIRECT SUPERVISION: Direct supervision signifies both the

control and the obligation in the p erformance of

professional services that meet or exc eed professional

standards of practice. It is th e act of a duly licensed

person for a speci fied professional discipline who either

personally prepares or was in responsible charge ov er

the preparation of work prod ucts and has a verifia ble

record that the individuals preparing such work products

were subject to regul ar and conti nuing review and

supervision during and t hroughout the development of

such products.

D

ISCIPLINES: In the context of professional practice, the

Board considers disciplines as those branches of

engineering and land surveying regulated by

Massachusetts law and w hich require special training

and knowledge.

E

NGAGEMENT NUMBER: Refers to a speci fic time per iod for

one employer or college associated with primarily one

experience category as listed in the experience table.

E

MPLOYER: To engage the services of personnel, as

defined by federal and state tax laws.

Engagement: employment periods demonstrating

experience or education at a given discipline.

E

XPERIENCE CLASSIFICATION: The amount of a specified type

of experience required for registration by the Board .

Usually associated w ith or linked to a s pecific type of

educational background.

F

IRM: A corporation, sole-proprietorship, proprietor trust,

P.A., LLP, LLC, company or co-partnership which offers

professional land survey ing services (as defined b y

Massachusetts General Laws) by letterhead or professional

listing and for whom others may be employed in that

service.

J

URISDICTION: A state, territory or legislative body with the

authority to regulate the practice of Land Surveying as

discrete and separate from other professional endeavors.

I

NTERVIEW: Per MGL, a n interview is part of the

examination process. (see Oral Exam)

L

AND SURVEYOR: A professio nal specialist in the te chnique

of measuring land, educated in the basic prin ciples of

mathematics, the related physical and ap plied sciences,

and the rel evant requirements of law for adequate

evidence and all requisite to the surveying of real property

and engaged in the practice of land surveying.

L

AND SURVEYING: Any service or work, the adeq uate

performance of which involves the application of special

knowledge of the principles of mathematics, the related

physical and appl ied sciences, and t he relevant

requirements of law for adequa te evidence to the act of

measuring and locating lines, angles, elevations, natural

and man–made features in the air, on the surface of the

earth, within underground workings, and on the bed s of

bodies of water for the purpose of deter mining areas and

volumes, for the monumenting of property boundaries, for

locating or relocati ng any o f the fi xed works embraced

within the practice of civi l engineering, and for the

platting, and layout of land and subd ivision thereof,

including the topography, alignment and grades of streets,

and for the pr eparation and perpetuation of maps, record

plats, field note records, an d property descrip tions that

represent these surveys.

L

AW OF EVIDENCE: The aggregate of ru les and principles

regulating the admissibility, relevancy, and weight and

sufficiency of evidence in legal proceedings.

L

ICENSE: A determination by a governing jurisdiction that a

person has completed the required courses of study and

acquired the necessary experience thorough a process of

application and examination following which the per son is

registered to practice professionally in that jurisdiction.

MGL: Massachusetts General Laws

MULTIDISCIPLINARY: A per son or firm having or emp loying

more than one professional discipline.

NCEES: The National Council of Examiners for Engineering

and Surveying. The corporation that prepares th e

Fundamentals examinations and the Principles and

Practices examinations for re gistration as ei ther an

engineer or land surveyor.

N

ON–RESIDENT: Any person who re sides outside the

Commonwealth of Mas sachusetts, whether or not their

employment is within the Commonwealth.

O

RAL EXAMINATION: A formal interview of a person,

arranged by the Board, to assess the qualifications of an

applicant prior to admittance to written examinations or

registration as a Professional Land Surveyor.

O

RGANIZATION: In the co ntext of this fo rm, means any

establishment, society, or concern established for the

benefit of the land surveying profession’s practitioners,

Page 5 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION INSTRUCTIONS

and concerned with issues such as professional ethics,

continuing education, public awareness, practice

interchange, etc.

P

RACTICE: see professional practice.

PRIMARY JURISDICTION: The jurisdiction where a

professionally licensed person was f irst

licensed/registered to practice land surveying.

P

ROFESSIONAL PRACTICE: Services offered by l icensed

members of a profession as defined by law, regulation,

or the normal practice of ot her competent, similarly

situated professional land surveyors of good repute.

R

ECIPROCITY: The Board i nterprets reciprocity to mean

the mutual or cooperative exchange of favors and

privileges, especially the exchange of rights or privileges

of licensing between jurisdictions. Massachusetts does

not grant licenses based upon this premise. (see comity)

REGISTRATION: The process by which th e Board firs t

determines that an applicant is qualified to practice and

then makes a formal record of such d etermination and,

by virtue of assigning each practitioner a unique license

or registration number, issues the practitioner a

certificate of such.

R

ESPONSIBLE CHARGE: Responsible charge experience

required for r egistration as a l and surveyor is tha t

portion of the technician’s experience that rises to the

level of a licensed practitioner by virtue of the degree of

responsibility accruing to the technician, provided tha t

such experience was gained while under the “direct

supervision” of a l icensed practitioner as required by

statute and r egulation. Such experience must provide a

clear indication to the Board that t he technician is

capable of pr oviding professional level services upon

becoming a registered or licensed practitioner.

Furthermore, such experience must be co mprised of a

diverse mix of those duties or responsibilities that would

normally accrue to the licensed practitioner, for instance

being responsible for the qu ality, review and evaluation

of surveying matters (in field and office) or thei r

presentation to clients, their agents, municipal boards,

and other such agencies or persons.

S

UPERVISOR: In this context, refers to the p erson who is

charged with all or part of t he responsibility of

overseeing aspects of a land surveying project. (see

direct supervision)

W

ORK PRODUCT: Work product s are ta ngible items

created or i dentified by the practitioner that

communicate information to the client or m embers of

the public regarding the practitioner’s opinion or the

services performed.

W

RITTEN EXAMINATION: An asse ssment mechanism

comprised of two examinations, the Fundamentals of

Surveying Examination (FS) and th e Principles and

Practices of Surveying Examination (PS). The FS exam is

an eight hour exam ination prepared by NC EES. The PS

exam is comprised of two parts, a six hour exam

prepared by NCEES and a two-hour jurisprudence

(state-specific) exam prepared by the Board.

Page 6 of 17

Updated 10/09/2015

Commonwealth of Massachusetts

Division of Professional Licensure

Board of Registration of Professional Engineers and Professional Land Surveyors

PROFESSIONAL LAND SURVEYOR REINSTATEMENT APPLICATION

www.mass.gov/dpl/boards/en

1. Applicant Name:

(last) (first) (middle)

2. Other Name:

(last) (first) (middle)

3. Residential Address:

(number) (street) (apt. #)

(post office box)

(city/town) (state) (zip code)

(email address)

4. Business Address:

(current employer) (company name)

(post office box) (or number, street, suite #)

(city/town) (state) (zip code)

(email address)

5. Address for correspondence: Residential P.O. Box Business

6. Date of Birth: 7. Place of Birth:

8. Citizenship: United States Other (specify)

9. Telephone Numbers (with area code):

Day:

Evening:

Attach a recent

passport 2” X 2” type

photograph of yourself

ADMIN. USE ONLY

Appl.#_________________

License#_______________

Type:_________________

Cash:_________________

Cash Date:_____________

Action:________________

______________________

Date:__________________

Page 7 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION

10. Do you currently or have you ever held a licenses/registrations

to practice Land Surveying or

Engineering in the United States or in a foreign jurisdiction other than Massachusetts

? If yes, then

complete the top section of “Attachment A” indicating the status of all license/certification ever held and

any relevant disciplinary information.

Yes

No

11. If you were practicing land surveying during the period of lapsed license, was that practice unlawful (did

you continue to provide professional services or continue to sign and seal plans, documents,

specifications)? If yes, then provide the specifics in the correspondingly numbered table entry entitled

“Attachment A – General Information”

Yes

No

12.

Has a licensing/registration Board located in the United States or any country of foreign jurisdiction

taken any disciplinary action against you? If yes, then provide the specifics in the correspondingly

numbered table entry entitled “Attachment A – General Information.”

Yes

No

13. Are you the subject of pending disciplinary actions by a licensing/registration Board located in the

United States or any country of foreign jurisdiction? If yes, then provide the specifics in the

correspondingly numbered table entry entitled “Attachment A – General Information”

Yes

No

14. Have you ever voluntarily surrendered or resigned a professional lic

ense/registration to a

licensing/registration Board in the United States or any country or foreign jurisdiction? If yes, then

provide the specifics in the correspondingly numbered table entry entitled “Attachment A – General

Information.”

Yes

No

15. Have you ever applied for and been denied a professional license/registration in the United States or

any co

untry or foreign jurisdiction? If yes, then provide the specifics in the correspondingly numbered

table entry entitled “Attachment A – General Information”)

Yes

No

16.

Have you ever been convicted of a felony or misdemeanor in the United States or any country or foreign

jurisdiction, other than a traffic violation for which a fine of less than $300.00 was

assessed? If yes,

then provide the specifics in the correspondingly numbered table entry entitled “Attachment A – General

Information.”

NOTE: The Board is certified by the Criminal History Systems Board [ID# MAREG G] to access data

about convictions and

pending criminal cases. Those records and other Federal and professional

records may be checked as part of your licensing process. No records are automatic disqualifiers; you

will be given an opportunity to discuss any issues with the Board.

Yes

No

17.

Did you obtain any of your education or professional experience under a different name? If yes, then

provide the specifics in the correspondingly numbered table entry entitled “Attachment A – General

Information”

Yes

No

18. Are you currently employed in a profession other than land surveying or in a position that does not

involve the practice of land surveying? If yes, then provide the specifics in the correspondingly

numbered table entry entitled “Attachment A – General Information”

Yes

No

19. Have you previously taken NCEES sanctioned Fundamentals of Land Surveying examinations? Yes No

Jurisdiction

Date of exam

Exam Score:

Pass Fail Disqualified

Jurisdiction

Date of exam

Exam Score:

Pass Fail Disqualified

Jurisdiction

Date of exam

Exam Score:

Pass Fail Disqualified

Page 8 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION

20. Have you previously taken NCEES sanctioned Principles & Practices of Land Surveying examinations? Yes No

Jurisdiction

Most recent date:

Times Taken:

Exam Hours:

Exam Score:

Pass Fail Disqualified

Jurisdiction

Most recent date:

Times Taken:

Exam Hours:

Exam Score:

Pass Fail Disqualified

Jurisdiction

Most recent date:

Times Taken:

Exam Hours:

Exam Score:

Pass Fail Disqualified

Jurisdiction

Most recent date:

Times Taken:

Exam Hours:

Exam Score:

Pass Fail Disqualified

21. Have you previously take the Massachusetts State-Specific (Jurisprudence) Land Surveying Exam? Yes No

Most recent date:

Times taken

Exam Hours:

Exam Score:

Pass Fail Disqualified

22. List your membership/affiliations in land surveying organizations or societies:

NAME

G

RADE OF

MEMBERSHIP

M

EMBER

SINCE

O

FFICES HELD

23. List schools & colleges attended (see instructions)

INSTITUTION CITY, STATE YEAR–YEAR CURRICULUM DEGREE EARNED CREDITS

High School

N/A N/A

Preparatory School

N/A N/A

College/University

(list only accredited academic courses of study)

Page 9 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION

24. List your ten most recent non-degree or non-academic courses of study (workshops, seminars, etc.):

COURSE TITLE OFFERED BY DATE CEU’S/PDH’S

(for all non degree courses of study, work shops, seminars, etc.)

25. List any independent programs of study in land surveying which would indicate your qualifications as a land

surveyor:

SUBJECT SPONSOR DATE NARRATIVE

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

R

EFERENCE

N

ARRATIVE

:

(Includes correspondence school, self study programs, research projects, etc. Attach narrative for each.)

Page 10 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION

26. Experience Table (read instruction carefully before completing this section)

(a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l)

Engagement Number

EXPERIENCE CATEGORY

(see instructions for designations)

BEGINNING DATE

(month/Year)

ENDING DATE

(month/Year)

ELAPSED TIME

(decimal years to nearest tenth)

SUPERVISING LAND SURVEYOR

(include license # & Jurisdiction, current

daytime telephone # and their employer

for that period)

YOUR EMPLOYER

(company name, address and telephone

number)

ELAPSED TIME

(for this engagement)

PRE-RESPONSIBLE CHARGE

(Surveying Experience)

RESPONSIBLE CHARGE

(Surveying Experience)

PROFESSIONAL L.S.

(Surveying Experience)

TOTAL (columns f, g, h)

(Surveying Experience)

OTHER

(non-surveying & academic)

Earliest date of registration in Massachusetts for license being reinstated: (do not show entries in table prior to this date)

1

2

3

4

5

6

TOTALS: (column e thorough j)

Page 11 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION

AFFIDAVIT & NOTARIZATION

“The undersigned applicant acknowledges that the Commonwealth of Massachusetts Board of Registration of

Professional Engineers and Professional Land Surveyors (Board), by its usual standards and procedures, will examine

and compile a record with respect to all aspects of the applicant’s surveying career. The applicant agrees to provide

any additional information in connection with the inquiry as may be required by the Board.”

“The applicant certifies that the information contained herein truthfully and accurately reflects the applicant’s

employment and educational background and that the supplemental materials provided are examples of work

prepared exclusively by the applicant except as specifically noted thereon. The applicant authorizes the Board to make

such investigations and inquiries as may be necessary to substantiate the statements supplied herein. This may

include contacting the employers, references and supervisors named herein. Applicant understands that any address

or telephone number found to be invalid at the time of the application will automatically invalidate that portion of the

submission and may result in a rejection of the application.”

“I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application

for licensure is truthful and accurate. I understand that the failure to provide accurate information may be grounds for

the Board to deny the application or to suspend or revoke a license issued to me, if said license is issued based upon

fraudulently supplied information. I further attest that, pursuant to MGL C62, §49A, to the best of my knowledge and

belief, I have filed all state tax returns and paid all state taxes required by law.”

“I further certify that I have read and understand the applicable laws, rules and regulations of the Commonwealth of

Massachusetts (MGL c112, s81D – 81T and 250 CMR) and the instructions that accompany this application.”

______________________________________________ ___________________

(signature of applicant) (date)

NOTARY

Jurisdiction of: ________________________________ County of: _________________________SS:____________

I, ___________________________________, a Notary Public in and for said county, in the jurisdiction aforesaid, DO

HEREBY CERTIFY that ____________________________________ personally known to me to be the same person

whose name is subscribed to the foregoing instrument, appeared before me this day in person, and acknowledged

that he/she signed, sealed and delivered the said instrument as his/her free and voluntary act, for the uses and

purposes therein set forth.

Given under my hand and notary seal this _____ day of ______________, 20____

_____________________________________ _____________________

(Notary Public Signature) (my commission expires)

Notary Seal

Page 12 of 17

Updated 10/09/2015

PLS REINSTATEMENT APPLICATION

Attachment A

Section 10 Response: Provide information for other engineering and land surveying licenses/certifications

(see instructions for required

“Request for Verification”; provide supplemental sheets if necessary)

JURISDICTION TYPE DATE ISSUED NUMBER STATUS DISCIPLINARY ACTION

Yes No

(status: current, inactive, suspended, probation, etc.)

If your answer was yes for any of the questions in sections 11 thorough 18 then you must provide an

explanation in the corresponding box below.

Section 11 Response

Section 12 Response

Section 13 Response

Section 14 Response

Section 15 Response

Section 16 Response

Section 17 Response (refer to engagement number in experience table that this response applies to)

Section 18 Response (refer to engagement number in experience table that this response applies to)

Page 13 of 17

Updated 10/09/2015

PLS Reinstatement Application

Experience Engagement Coversheet

(FILL OUT ONE COPY OF THIS SHEET FOR EACH OF SECTION 27

S

ENGAGEMENTS AND ATTACH IT TO THE ASSOCIATED REFERENCE MATERIALS)

E

NGAGEMENT

N

UMBER

:

E

NGAGEMENT CATEGORY

:

(3

LETTER ACRONYM

)

T

YPICAL

D

UTIES

A

SSOCIATED

W

ITH

T

HIS

E

NGAGEMENT

:

S

COPE OF

E

XPERIENCE

A

SSOCIATED

W

ITH

T

HIS

E

NGAGEMENT

:

L

EVEL OF

R

ESPONSIBILITY

A

SSOCIATED

W

ITH

T

HIS

E

NGAGEMENT

:

T

YPES OF

A

TTACHED

D

OCUMENTATION

:

P

ROFILE OF

M

ULTIDISCIPLINARY

F

IRM

’

S

ERVICES

(

IF APPLICABLE

):

P

ROFILE OF

F

IRM

’

S

T

YPICAL

S

URVEYING

S

ERVICES

:

Page 14 of 17

Updated 10/09/2015

Commonwealth of Massachusetts

Division of Professional Licensure

The Board of Registration of Professional Engineers and Professional Land Surveyors

Request for Verification

For Non-Massachusetts License, Registration, Examination, Standing

Applicant requesting status of registration/license/examination: (to be filled out by applicant)

Name:

Type of License/Registration:

Street Address:

License/Registration #:

Other:

Last four digits of SS#:

City:

Date of Birth:

State:

Zip:

Status of applicant’s Certificate/Registration/License: (to be filled out by jurisdiction)

Record Certif. No. Date Issued Valid Until Disciplinary Actions

Engineer In Training EIT Yes No

Professional Engineer PE Yes No

Surveyor in Training SIT Yes No

Professional Land Surveyor PLS Yes No

Other:

Yes No

Disciplinary Actions:

Applicant’s examination record: (to be filled out by jurisdiction)

Exam Hours Result Date NCEES Exam Branch

FE Pass Fail Yes No

P&PE Pass Fail Yes No

FLS Pass Fail Yes No n/a

P&PLS Pass Fail Yes No n/a

Oral Pass Fail By Board

Other:

Pass Fail Yes No

Remarks:

Processing agency’s Instructions:

Return completed form to:

Attested By:

Board Seal:

DPL, Board of Engineers and Land Surveyors

1000 Washington Street, Suite 710

Boston, MA 02118

Signature:

Title:

Date:

Page 15 of 17

Updated 10/09/2015

Page 1 of 2

COMMONWEALTH OF MASSACHUSETTS

1000 Washington Street, Suite 710

Boston, MA 02118-6100

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to

M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of M.G.L. c.

6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective license applicants

and current licensees.

As a license applicant or current licensee, I understand that a CORI check will be submitted for my personal

information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby acknowledge and

provide permission to the Division of Professional Licensure to submit a CORI check for my information to the

DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at

any time by providing the Division of Professional Licensure written notice of my intent to withdraw consent to a

CORI check.

FOR LICENSING PURPOSES ONLY:

I understand that the Division of Professional Licensure may conduct a subsequent CORI check within one year of

the date this Form was signed by me.

By signing below, I provide my consent to an initial CORI check and a subsequent CORI check, both within one

year of the date of this Form, and acknowledge that the information provided on Page 2 of this Acknowledgement

Form is true and accurate.

_________________________________ _________________________________

Signature Date

Please provide the name of the board of registration and license type for which you are applying or currently hold:

_________________________________ _________________________________

Board of Registration License Type

NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS

EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL EMPLOYEE

WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE IDENTIFICATION, OR (2)

SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE VERIFIED IDENTITY AND

THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES AT THE ADDRESS SET FORTH

ABOVE.

Page 2 of 2

SUBJECT INFORMATION: (A red asterisk (*) denotes a required field)

__________________________________________________________________________________________

*Last Name *First Name Middle Name Suffix

__________________________________________________________________________________________

*Maiden Name (or other name(s) by which you have been known)

___________________ ____________________________

*Date of Birth Place of Birth

* Social Security Number: ________-________-_________

Sex: ______ Height: ____ ft. ____ in. Eye Color: _________

Driver’s License or ID Number: ___________________ State of Issue: ___________________

Current and Former Addresses:

____________________________________________________________________________________________

Street Number & Name City/Town State Zip

____________________________________________________________________________________________

Street Number & Name City/Town State Zip

_________________________________________________________________________________________________

IDENTITY VERIFICATION SECTION: If this form is submitted by hand at DPL Offices,

Section A must be completed. Otherwise, Section B must be completed.

SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the above-referenced

subject by reviewing the following form(s) of government-issued identification:

1

 Passport  State-issued driver’s license  Military identification  State-issued identification card

VERIFIED BY: ________________________________________________________________________________

Name of Verifying DPL Employee (Please Print)

________________________________________________________________________________

Signature of Verifying DPL Employee Date

___________________________________________________________________________________________________

SECTION B: VERIFICATION BY NOTARY:

On this ______ day of _____________, 20____, before me, the undersigned notary public,

personally appeared

_________________________________ (name of document signer), and proved to me through satisfactory evidence of identification,

which was the following:

1

 Passport  State-issued driver’s license  Military identification  State-issued identification card

to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it

voluntarily for its stated purpose.

_____________________________________________________________________________________________

Notary Public: Notary Commission Expires On

1

If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by other forms of

documentation as determined by DCJIS. 803 CMR 2.09(2).

Fill Online, Printable, Fillable, Blank Ls-reinstatement Updated (Commonwealth of Massachusetts) Form

Related forms

Fillable Ls-reinstatement Updated (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Ls-reinstatement Updated (Commonwealth of Massachusetts) Form

Related forms

First 20 documents completely FREE!