RE: __________________________
For office use only
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
Professional Engineer Reference Form
(Please print clearly.)
N
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_________________________________________________
_____________________________________________
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 filled 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 confidential. This statement must be received in the Board office 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 engineer. Statements by responsible people with actual knowledge of the experience
and qualifications of the applicant will be considered by the Board as meeting this provision of the law.
The practice of professional engineering 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 engineering 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