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
Certicate of Authorization Application
Pursuant to N.J.S.A. 45:8-56
* You must complete the “Details of Ownership” pursuant to N.J.S.A. 45:8-57.
Note: Print clearly or use a typewriter. If any space is inadequate for any portion of this form, use a separate sheet of paper.
Name and address of the corporation Contact person’s phone no. Date of this application
Name and Address of registered agent in New Jersey
Addresses of the satellite ofces in New Jersey where professional services will be offered or provided (each ofce
must be sequentially numbered beginning with 2; as in 2, 3, 4, etc.).
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
Name and license number of the licensee in responsible charge in the principal ofce.
Name and license number of the licensee in responsible charge in each additional ofce.
Name License number
2. __________________________________________________________________ ____________________
3. __________________________________________________________________ ____________________
4. __________________________________________________________________ ____________________
Every person in responsible charge listed below must include the numeric identier of his or her work location
following his or her name in the column below.
List all personnel in-responsible-charge who act on behalf of the corporation as a professional engineers or land surveyor.
Name
Prof. Prof. Home address X Signature
Land Surveyor
Engineer
( )
( )
( )
( )
( )
( )
( )
Any changes in the above information must be reported to the Board within 30 days after such changes become effective.
Under oath, I declare that the foregoing statements, to the best of my knowledge and belief, are true and made in good faith.
____________________________________________ _____________________________________________ __________________________
Print the name of the Chief Executive Ofcer Signature of the Chief Executive Ofcer Date
Corporation Section (for corporations and limited liability companies)
Name of corporation
Print the name of the authorized ofcer Title
Signature of the authorized ofcer
Date
CheCk One:
Professional Engineering
Land Surveying
Engineering and Land Surveying
I hereby certify that I am familiar with the
laws and
regulations governing the practices
of professional
engineers or land surveyors in New Jersey and
the denition of “responsible charge” therein,
and my responsibility under this denition.
Before me personally appeared the signer of the above, who acknowledged
himself/herself to be the authorized above-named officer (or managing
member) of the above-named corporation, and that he/she being authorized
to do so, executed this application for the purposes stated by signing
the name of the corporation by himself/herself as the authorized officer.
In witness thereof:
Subscribed and sworn to before me this day of ___________________, _______ .
County ____________________State ______________
Print name of notary public ______________________
Signature of notary public _______________________
Date commission expires ________________________
affix
notary
public
seal
affix
corporate
seal
(Corporations only)
(include area code)
I have attached the required certied copy of the
Certicate
of Incorporation/Authority/Formation from
the N.J. Dept. of the Treasury.
Yes No
Submit a copy of the
most current annual
report f i led w i t h
Division of Revenue
in the New Jersey
D e p a r t m e n t o f
Treasury.
N.J. license number
click to sign
signature
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click to sign
signature
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