Land Surveying Form 3 - Verification Of Out Of State Licensure, Registration And/or Examination - 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 3
Division of Professional Licensing Services
Verification of Out-Of-State Licensure, Registration
and/or Examination
(Use this form only if you are or have been licensed as a land surveyor in another jurisdiction or if you want to verify that you
passed the Fundamentals of Land Surveying Examination and/or the Principles and Practice of Land Surveying examination in
another jurisdiction.)
Applicant Instructions
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and
date item 8.
2.
Send this entire form to the appropriate licensing authority for completion of Section II. Be sure to include any fee required by that
licensing authority. If applying for 7208(b) Interim practice, verification of licensure/certification from your current jurisdiction of residence
is required. This form will not be accepted if submitted by the applicant.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
Print Name as It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
4.
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
5
If licensed by examination in the United States, give jurisdiction: _________________________________________________________
6
6.
Print or type your name in the exact form in which land/surveying license was issued:
____________________________________________________________________________________________________________
7
7.
To the Land Surveying State Board of: _____________________________________________________________________________
Check appropriate boxes:
I hereby make application for the transfer of examination grades and related information.
I am a licensed certified Land Surveyor of your jurisdiction. License number: __________________ Date: ______ / ______ / ______
mo.
day
yr.
8
8.
I request and give my permission to the licensing authority listed in item 7 above to complete the information on this form and mail it to
the New York State Education Department and to release any other information required by the State Education Department in
connection with my application for licensure. I also declare and affirm that the statements made in this application, including
accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in connection
with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.
_________________________________________________________________________________ _______ / _______ / _______
Applicant’s Signature
mo.
day
yr.
Land Surveyor Form 3, Page 1 of 3 (Rev. 5/09)

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