New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
P.O. Box 45015, Newark, New Jersey 07101
(973) 504-6460
Verication of Registration
From: New Jersey State Board of Professional Engineers and Land Surveyors
To: _________________________________________ Date: ________________________________________
State: ______________________________________ Name of applicant: _____________________________
Name: ______________________________________ Street address: ________________________________
Street: ______________________________________ City, State, ZIP code: ____________________________
City, State, ZIP code: __________________________
I. The above-named person was registered as:
Certicate Number Date Issued Valid Until
❏ Professional Engineer…… ______________________ _______________ ______________
❏ Engineer-in-Training…….. ______________________ _______________ ______________
❏ Land Surveyor…………… ______________________ _______________ ______________
❏ Architect…………………. ______________________ _______________ ______________
II. Minimum Requirements were:
1. ❏ Written Examination
Number of hours: PE _____________ hrs. EIT ______________ hrs. LS ______________ hrs.
Grade/date of exam: PE ___ (___/___/___) EIT ___ (___/___/___) LS ___ (___/___/___)
grade date grade date grade date
If NCEES examinations, were these grades based on recommended cut-off scores? _____________________
EIT accepted from: _____________________________ PE accepted from: ___________________________
2. ❏ Oral Examination
Number of hours: PE _____________ hrs. EIT ______________ hrs. LS ______________ hrs.
3. Discipline: ______________________________
4. Comity with: (1) ______________________________________ (2) _____________________________________
5. Other: Please give full details on other side.
6. State-Specic Examination: ____________________
7. Have there been any disciplinary actions initiated against this individual?
❏ Yes ❏ No
If so, please describe said actions on the reverse side and provide any and all documents:
By: ________________________________________
Title: _______________________________________
Date: ______________________________________
***This form must be completed by the issuing state.
(SEAL)
Applicant number:
