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as a Land Surveyor-In-Training Instructions for Completing an (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
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Instructions for Completing an Application for Certication
as a Land Surveyor-In-Training
Application:
1. Complete the application available at:
www.njconsumeraffairs.gov/pels/Applications/Land-Surveyor-in-Training-Application.pdf
forCerticationasaLandSurveyor-in-Training.AnswerALLofthequestions.
2. Signtheapplicationinthepresenceofanotarypublic(page6).Yourapplicationmustbenotarizedoritwillbereturnedtoyou,
whichwilldelaytheprocess.
3. Attachaclear,full-faceoriginalcolorpassport-stylephotograph(2”x2”)ofyourheadandshoulderstakenwithinthepastsix
months.(Photocopiesandseleswillnotbeaccepted.)
4. Ifyouarealegalalienorotherimmigrationstatus,pleasesubmityourUSCISimmigrationdocuments.(Submitacopyofboth
thefrontandthebackofyourcard.)
5. Submitcriminalhistorydocuments(ifapplicable).
6. Submitanon-refundableapplicationfeeintheformofacheckormoneyorder,payabletotheStateofNewJersey,intheamount
of$30.00.
References:
1. Submit three (3) references on Board-approved forms available for downloading at: www.njconsumeraffairs.gov/pels/
Applications/Land-Surveyor-in-Training-Reference-Form.pdf.Oneofthethreereferencesmustbefromalicensedprofessional
landsurveyorintheUnitedStates.
Fundamentals of Land Surveying Examination:
SubmitproofofpassingtheFundamentalsofLandSurveying(FS)exam.Pleaseindicatethestateanddateyoutooktheexamatthe
topofpage4oftheapplication.You do not need to obtain Board approval or submit an application to the Board prior to taking the
FS exam. Information about the FS exam may be found at:http://ncees.org/surveying/fs/.
Education Evaluation:
Ifyouhaveanundergraduatedegreefromanon-ABETaccreditedprogram,thenyoureducationcredentialsmustbeevaluated.
TheBoardrecommends:1)NCEES;2)JosefSilny;or3)EducationalPerspectives.PleaserequestaSubjectAnalysisevaluation.
 Contactinformationisavailableat:www.njconsumeraffairs.gov/pels/Pages/applications.aspx.
Please submit all of the above-referenced documents to:
State Board of Professional Engineers and Land Surveyors
124HalseyStreet,3rdFloor
P.O.Box45015
Newark,NewJersey07101
New Jersey Ofce 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
Anonrefundableapplicationlingfeeof$30,intheformofacheckormoneyordermadeouttotheStateofNewJersey,mustbe
submittedwiththisapplication.(Applicantsshouldunderstandthatiftheapplicationlingfeeispaidwithapersonalcheck,andthe
checkisreturnedbythebankduetoinsufcientfunds,thenextstepinthelicensureorcerticationprocesswillbedelayeduntilthefee
ispaid.)PleaseseetheFeeScheduleforthelicensefeeat:http://www.njconsumeraffairs.gov/pels/Applications/Professional-Engineers-
and-LandSurveyors-Fee-Schedule.pdf.
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
tothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.
Informationthatyouprovideonthisapplication(includingyouraddressofrecord)maybesubjecttopublicdisclosureasrequiredby
theOpenPublicRecordsAct(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Dateofbirth:_________________________
MonthDayYear
Placeofbirth:________________________
Mr.
1. Name Mrs. __________________________________________________________ (_____________________ )
 Ms.
Lastname Firstname Middleinitial Maidenname
2. Address
Home:_____________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
_________________________________ _______________________________
Telephonenumber(includeareacode) E-mailaddress
 Business: __________________________________________________________________________________
Nameofcompany Telephonenumber(includeareacode)
___________________________________________________________________________________
Street City State ZIPcode County
 Mailing:___________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
NCEESRecordNumber(ifapplicable):_______________________________
Attachaclear,full-facepassport-
stylephotograph(2˝x2˝)ofyour
headandshoulders,takenwithin
thepastsixmonths.
A photo is required with each
application.
Donotuseapapercliptoattach
thephoto.
-1-

Rev.10/12/17
For ofce use only
Application
number _______________________
Date_________________ ,________
Land Surveyor-in-Training Application
(Tobecompletedbytheapplicantonly.)
3. SocialSecurityNumber
YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/nonrenewalof
licensureorcertication.
*SocialSecurityNumber:  __________ -____________ -___________
*PursuanttoN.J.S.A.54:50-24et.seq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupport
EnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeis
requiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovide
yourSocialSecuritynumberto:
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing
compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;and
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. ChildSupport
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresultinadenialof
licensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimited
to,immediaterevocationorsuspensionoflicensureorcertication.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
-2-
click to sign
signature
click to edit
-3-
6. Haveyou ever beensummoned; arrested; takeninto custody; indicted;tried; charged with; admittedintopre-trial intervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No
7. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty,
nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury.  Yes No
If“Yes,”provideacopyofthejudgmentofconvictionandthereleasefromparoleorprobation.Pleaseprovideacompleteexplanation.
(Attachadditionalsheetsofpapertothisapplication.)
8. Do you currently hold, or have you ever held, a professional or occupational license or certicate (i.e. radon measurement
 technician or specialist, radon mitigation technician or specialist, etc.) of any kind in New Jersey, any other state, the
DistrictofColumbiaorinanyotherjurisdiction?   Yes No
If“Yes,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicenseorcerticatewasissuedunder
adifferentname,pleaseprovidethatname.____________________________________________________________________
LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
9. HaveyoueverbeendisciplinedordeniedaprofessionallicenseorcerticateoranyotherprofessionallicenseorcerticateinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
10. Haveyoueverhadaprofessionallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
11. Hasanyaction(includingtheassessmentofnesorotherpenalties)everbeentakenagainstyourprofessionalpracticebyanyagency
orcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
12. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofprofessionallandsurveyingorotherprofessional
practiceinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
13. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
14. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction?  Yes No
15. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgroup
relatedtothepracticeofprofessionallandsurveyingorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictof
Columbiaorinanyotherjurisdiction?  Yes No
Iftheanswertoanyoftheabovequestions,numbers9through15,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
- 4 -
16. Present License status
Do you currently have on le, or have you ever led, a land surveyor–in–training application in New Jersey?
Yes No If “Yes,” please supply the application number. ________________________
Have you passed any portion of the land surveyor’s examination in any other state? Yes No
If the answer to the above question is “yes,” please list the states and the dates of the examinations.
Fundamentals
Principles & Practices
Exam State Date
State Portion
17. references of character and QuaLifications
Give the name and address of three references not related to you. One of these references must hold a valid United States
land surveyor’s license and have knowledge of your experience or training. No member of the Board will be accepted as
a reference. The applicant must download and distribute one form to each individual listed as a reference. Click on the
link www.njconsumeraffairs.gov/pels/Applications/Land-Surveyor-in-Training-Reference-Form.pdf for the reference
form. The signature of each person used as a reference is not required below.
(Fill out completely–do not refer to other forms, etc.)
______________________________________________________________________________________
Name Address Licensed in state of License Number
______________________________________________________________________________________
Name Address Licensed in state of License Number
______________________________________________________________________________________
Name Address Licensed in state of License Number
-5-
18. education*
(Fill out completely–do not refer to other forms, etc.)
Bachelor’sDegreeinlanDsurveying
______________________________________________________________________________________
NameandLocationofInstitution Full-Time/Part-Time Years(From/To) DateGraduated CurriculumDegreeReceived
______________________________________________________________________________________
NameandLocationofInstitution Full-Time/Part-Time Years(From/To) DateGraduated CurriculumDegreeReceived
______________________________________________________________________________________
NameandLocationofInstitution Full-Time/Part-Time Years(From/To) DateGraduated CurriculumDegreeReceived
graDuateDegreeinlanDsurveying
______________________________________________________________________________________
NameandLocationofInstitution Full-Time/Part-Time Years(From/To) DateGraduated CurriculumDegreeReceived
______________________________________________________________________________________
NameandLocationofInstitution Full-Time/Part-Time Years(From/To) DateGraduated CurriculumDegreeReceived
______________________________________________________________________________________
NameandLocationofInstitution Full-Time/Part-Time Years(From/To) DateGraduated CurriculumDegreeReceived
* An ofcial transcript must be submitted to the Board ofce directly from the institution. This requirement also
applies to applicants educated in a foreign country.
-6-
affidavit
This afdavit is to be executed by the applicant before a notary public:
Stateof:_____________________________________________
Countyof:___________________________________________
I, ___________________________________________ , in making this application to the State Board of Professional
EngineersandLandSurveyorsforlicensureorcerticationundertheprovisionsofTitle45oftheGeneralStatutesofNew
JerseyandtheRulesof theStateBoardof ProfessionalEngineersandLandSurveyors,swear(orafrm)that Iamthe
applicantandthatallinformationprovidedinconnectionwiththisapplicationistruetothebestofmyknowledgeandbelief.
Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufcienttodenylicensure
orcerticationortowithholdrenewaloforsuspendorrevokealicenseorcerticateissuedbytheBoard.
Iswear(orafrm)thatIhavereadN.J.S.A.45:8-27etseq.,togetherwiththeRulesandRegulationsoftheStateBoardof
ProfessionalEngineersandLandSurveyors,N.J.A.C.13:40-1.1through13:40-13.9,andfullyunderstandthatinreceiving
licensureorcerticationfromtheBoard,Ibindmyselftobegovernedbythem.
Ifurtherswear(orafrm)that,pursuanttoN.J.S.A.45:8-35,IamabletospeakandwriteEnglishlanguage.
Furthermore,Ivoluntarilyconsenttoathoroughinvestigationofmypresentandpastemploymentandotheractivitiesforthe
purposeofverifyingmyqualicationsforlicensureorcertication.Ifurtherauthorizeallinstitutions,employers,agencies
andallgovernmentalagenciesand instrumentalities(local,state, federalorforeign) toreleaseany information,les or
recordsrequestedbytheBoard.
_____________________________________________
Applicant’ssignature
Swornandsubscribedtobeforemethis_____________
dayof _________________________ ,____________
Afx Seal Here
MonthYear
_____________________________________________
NameofNotaryPublic(pleaseprint)
_____________________________________________
SignatureofNotaryPublic
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as a Land Surveyor-In-Training Instructions for Completing an (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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