Land Surveying Form 5 - Notification Of Intent To Practice Land Surveying Under Section 7208(B) Of Education Law - New York The State Education Department

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The University of the State of New York
Land Surveyor
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 5
Division of Professional Licensing Services
Notification of Intent to Practice Land Surveying Under Section
7208(b) of Education Law
Applicant Instructions
Complete this form. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date
item 7 before submitting this form along with your Licensure Application (Form 1) to the Office of the Professions at the address at the end
of the form.
2.
1
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2
3.
Birth Date
Month
Day
Year
3
5
6.
Telephone/E-Mail Address
4.
Print Name
Daytime phone
Last
First
Area Code
Phone
Middle
E-mail Address
4
5.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Statement of Intent
This is to state my intent to practice land surveying in the State of New York during the time when my application for licensure is being
reviewed by the State Board for Engineering and Land Surveying, as permitted by Subsection (b) of Section 7208 of the New York State
Education Law.
I am currently authorized to practice in the State (or Country) of ___________________________________, and have requested the
licensing authorities from that state (or country) to submit Form 3, Verification of Out-of-State Licensure, Registration and Examination
directly to the Department.
I do not have an established place of business in the State of New York. My current state of residence is shown in item 4 above, and if
I am now a resident of the State of New York, this is to certify that I have resided in New York for a period of less than six months
beginning on _______________________________ of _________________.
Month
Year
Attestation
7
I understand that my authorization to practice under Section 7208(b) does not become effective until the Department determines that
my application is complete and sends me an authorization letter.
Signature _______________________________________________________________________ Date ________________________
Print name ______________________________________________________________________
Mail this form with your Application for Licensure (Form 1) and appropriate fee to: New York State Education Department, Office
of the Professions, PO Box 22063, Albany, NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York
State Education Department
Land Surveyor Form 5 Rev. 8/15

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