Fillable Professional Land Surveyor Reference Form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Professional Land Surveyor Reference Form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce 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
Professional Land Surveyor Reference Form
(Please print clearly.)
Name of Reference Name of Applicant
_____________________________________________ _____________________________________________
Last name First name Middle initial Last name First name Middle initial
_____________________________________________ _____________________________________________
Street address Street address
_____________________________________________ _____________________________________________
City State ZIP code City State ZIP code
The applicant for licensure, whose name and address appear above, has sent you this request for a reference statement and
has referred to you as someone who has personal knowledge of his/her character and professional experience. Also, attached
to this form is the appropriate section of the applicant’s “Description of Experience” for your review and validation. Please do
not return this reference form without the attached “Description of Experience.”
Your prompt completion and return of this statement, properly lled in and signed in the appropriate location, will assist
the State Board of Professional Engineers and Land Surveyors (the Board) when considering the applicant for licensure. Your
response to this request will be condential. This statement must be received in the Board’s ofce by ____________________
if the applicant is to be considered for the next scheduled examination.
The Board is statutorily required to obtain evidence of the professional experience and good character of all those who apply
for licensure as a professional land surveyor. Statements by responsible people with actual knowledge of the experience and
qualications of the applicant will be considered by the Board as meeting this provision of the law.
The practice of professional land surveying involves relationships with the public that necessitate a high degree of honor,
integrity and professional ability. The Board trusts that when completing this form, you fully understand that the purpose of the
law is to protect the public from the practice of land surveying by people who are not competent to engage in such a practice.
Please return this statement directly to:
State Board of Professional Engineers and Land Surveyors
P.O. Box 45015
Newark, N.J. 07101
For ofce use only
Re: ____________________________
You may be requested to substantiate any statements made herein.
Statement of endorSer
(This form should not be lled out in the presence of the applicant. Please print clearly.)
1. a. How many years have you known the applicant on a personal basis? _______________________________________
b. How many years have you known the applicant in your professional capacity? _______________________________
2. How would you characterize the applicant’s character and personal reputation?
Excellent Good Unacceptable Not known
If “Unacceptable,” please explain:
.
3.
You are the applicant’s: Manager/Director Direct Supervisor Co-worker/Colleague Subordinate
Other _______________________________________________________________________
4. Is your knowledge of the applicant’s surveying experience based exclusively on your relationship described in
question three? Yes No
If “No,” please indicate the basis of your knowledge:
.
5. Please comment on the applicant’s ability to effectively communicate, both verbally and in writing, in the English
language.
6. Please comment on the applicant’s knowledge and application of surveying principles.
7. Please comment on the applicant’s development of surveying judgment and work accuracy.
8. Please comment on the applicant’s ability to assume responsibility and direct people.
9. Please comment on the applicant’s ability to recognize and work within his or her own limitations.
10. From your personal knowledge, please list the type of work the applicant has performed and provide the details of
his or her responsibilities.
11. From your personal knowledge, for how many years has the applicant been engaged in land surveying? ___________
12. a. Please refer to the attached “Description of Experience.” How much of the time noted in question 11 has the
applicant been involved in land surveying work under the direct supervision of a professional land surveyor?
_____________ years.
b. Please note the engagement(s) in the attached “Description of Experience” with which you are familiar:
________________________________________________________________________________________.
13. Do you consider that the applicant has reached a professional level in his or her work?
14. The Board would appreciate any additional information that you may wish to provide.
15. If you have any reason to believe that licensure of the applicant should be withheld at this time, please comment
below.
16. If you are not a professional land surveyor, what is your business or profession?
________________________, _________.17. If you are a professional land surveyor, please provide your license number:
License number State of licensure
Your signature on this reference form indicates that you verify that the time and value of the applicant’s experience as
outlined on the attached “Description of Experience” is accurate to the best of your knowledge as of the date of your
signature.
__________________________________________________________ __________________________
Signature Date
_______________________________________
Telephone Number (include area code)
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Professional Land Surveyor Reference Form (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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