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Land Surveying Form 3 - Verification Of Out Of State Licensure, Registration And/or Examination - New York The State Education Department Page 3

Certification

I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named

above. I further certify that, except as noted in item 3 on page 2 or in any attachments, this licensing authority has never taken any

disciplinary action against this person and that in so far as the licensing authority has knowledge, there have been no charges preferred

nor has any information been presented relating to any question of unprofessional or immoral conduct.

Signature: _____________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print name: ____________________________________________________________________

Title: _________________________________________________________________________

Licensing authority: _____________________________________________________________

(SEAL)

Address: ______________________________________________________________________

City: ____________________________ State ____________ Zip Code ____________________

Telephone: _______________________________ Fax: _________________________________

E-mail Address: _________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

Land Surveying Unit, 89 Washington Avenue, Albany, NY 12234-1000.

Land Surveyor Form 3, Page 3 of 3 (Rev. 5/09)

Land Surveying Form 3 - Verification Of Out Of State Licensure, Registration And/or Examination - New York The State Education Department Page 3