Fillable as an Engineer-In-Training Instructions for Completing an Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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as an Engineer-In-Training Instructions for Completing an Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

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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 an Engineer-In-Training
Application:
1.
Complete the application available at: www.njconsumeraffairs.gov/pels/Applications/Professional-Engineer-in-Training-Application.pdf
forCerticationasanEngineer-in-Training.AnswerALLofthequestions.
2. Signtheapplicationinthepresenceofanotarypublic(page5).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 the namesof three (3) references on the application, (item #17), as well as download on Board approved forms
www.njconsumeraffairs.gov/pels/Applications/Professional-Engineer-in-Training-Reference-Form.pdf your references. One
ofthethreereferencesmustbefromalicensedprofessionalengineerintheUnitedStates.Pleasefollowtheinstructionsfound
inthissectionregardingdistributionofthereferenceformstoyourreferences.
Fundamentals of Engineering Examination:
SubmitproofofpassingtheFundamentalsofEngineering(FE)exam.Pleaseindicatethestateanddateyoutooktheexamatthe
topofpage4oftheapplication. You do not need to obtain Board approval or submit an application to the Board prior to taking the
FE exam. Information on the FE exam may be found at:http://ncees.org/engineering/fe/.
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.
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
Engineer–in–Training Application
(Tobecompletedbytheapplicantonly.)
Anonrefundableapplicationlingfeeof$30,intheformofacheckormoneyordermadepayable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.
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
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):_______________________________
For ofce use only
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
Application
number _______________________
Date_________________ ,________
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)Aof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
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releasefromparoleorprobation.Pleaseprovidea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engineering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 engineering 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.
-3-
16. PresentAPPlicAtionstAtus
Do you currently have on le, or have you ever led, an engineer–in–training application in New Jersey?
Yes No If “Yes,” please supply the application number. _____________________
If you have passed the Fundamentals of Engineering exam, please list the date and the State in which the exam was
taken: ________________________________________________________________________________________
Date Exam State
17. referencesofchArActerAndQuAlificAtions
Give the name and address of three references not related to you. One of these references must hold a valid United
States professional engineer’s license and have knowledge of your experience or training. The applicant must download
and distribute one form to each individual listed as a reference. Click on the link www.njconsumeraffairs.gov/pels/
Applications/Professional-Engineer-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
18. educAtion*
(Fill out completely–do not refer to other forms, etc.)
Bachelor’s Degree in engineering
______________________________________________________________________________________
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 Degree in engineering
______________________________________________________________________________________
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.
- 4 -
-5-
Afx Seal Here
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 _________________________ ,____________
_____________________________________________
NameofNotaryPublic(pleaseprint)
_____________________________________________
SignatureofNotaryPublic
Month
Year
} ss.
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as an Engineer-In-Training Instructions for Completing an Application (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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