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Land Surveyor - Application For Licensure - The University Of The State Of New York The State Education Department - 2016

Department Use Only

The University of the State of New York

Land Surveyor

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Form 1

Division of Professional Licensing Services

Application for Licensure

Applicants Must Complete All Pages of This Application In Ink

All applicants for licensure must complete this form and submit it with the appropriate fee ($377 licensure and

first registration, $70 for eligibility to take part 1 of the exam only) directly to the Office of the Professions at

the address at the end of this form. You must answer all questions and provide all information requested

unless otherwise indicated. Failure to complete all required parts of the application will delay its review. You

must sign and date the Affidavit on this form in the presence of a Notary Public.

Check what you are applying for:

NYS License Number

 Licensure and First Registration

15 $377

 Eligibility to take Part 1 of the Exam

Date Issued

$70

Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

Initials

Birth Date

Month

Day

Year

Print Name

Telephone/E-Mail Address

Last

Daytime phone

First

 Home or  Business

Middle

Area Code

Phone

Licensee business address, phone and e-mail address are public information. Failure to indicate

E-mail Address

(please print clearly)

business or home on this form for each item will deem it public information.

 Home or  Business

Mailing Address:

 Home or  Business

(You must notify the Department promptly of any address or name changes.)

Line 1

New York State DMV ID Number

Line 2

(Driver or Non-Driver ID)

Line 3

City

(Leave this blank if you do not have a New

York State DMV ID Number)

State

Zip Code

Country/

Province

Name as it appears on degree or other credentials (if different from above): ________________________________________________

I am applying for licensure and:

Eligibility for admission to examination(s):

Part 1: Fundamentals of Land Surveying. (8 hours)

Part 2: Principles and Practice of Land Surveying. (6 hours)

Part 3: New York State Specific Examination. (2 hours)

Transfer of examination grade(s) from other State(s) or U.S. Territory(ies). (Use Form 3)

Part 1: From state/territory of ____________________________, exam date: _______ / _______ / _______ No. of hours: _______

Part 2: From state/territory of ____________________________, exam date: _______ / _______ / _______ No. of hours: _______

Part 3: Grades are not transferable.

Yes

 No

10. Have you passed Part 1, the Fundamentals of Land Surveying Examination?

If “yes”, give state: _________________________________________________________________________

Yes

 No

Have you previously applied for New York State licensure in any profession?

If “yes”, in what profession(s)? _______________________________________________________________

Land Surveyor Form 1, Page 1 of 4 Rev. 6/16

Land Surveyor - Application For Licensure - The University Of The State Of New York The State Education Department - 2016

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