Form 9436 - Application For Registration To Practice As A Land Surveyor
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1
2APPLICATION FOR REGISTRATION
Application number
FOR OFFICE USE ONLY
TO PRACTICE AS A LAND
SURVEYOR
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Fees
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State Form 9436 (R7 / 12-02)
Review of application
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for examination. . $10.00
Approved by State Board of Accounts, 2002
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Application for COMITY
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E
registration to practice as
Check Appropriate Box
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a land surveyor. . $75.00
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Comity
Exam
This agency is requesting disclosure of personal information that is necessary to accomplish the statutory purpose of this board under IC 25-31. Disclosure of this information is
mandatory. Incomplete applications are subject to denial by the board. Upon completion, this form will be treated as a public record. * Your Social Security number is requested by
this agency in accordance with IC 4-1-8.1, which is mandatory, accessible by the Indiana Department of Revenue.
INSTRUCTIONS:
Type or print in ink. If necessary, attach extra sheets with each sheet dated and signed.
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Application must be accompanied by a recent photo.
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Application must be accompanied by appropriate fee payable to:
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Indiana Professional Licensing Agency.
Return application and all accompanying documents to:
Indiana Professional Licensing Agency
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302 W. Washington Street, Room E034
Indianapolis, IN 46204
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APPLICANT INFORMATION
Name of applicant (first, MI, last)
Have you ever had a name change?
P H O T O
Yes
No
Address (number and street)
Social Security number *
City, state, ZIP code
Date of birth (month, day, year)
Place of birth
Name of firm
Home telephone number
Business telephone number
Address (number and street, city, state, ZIP code)
(
)
(
)
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COLLEGE INFORMATION (Attach certified copy of transcripts from each school attended.)
Business Telephone
Dates Attended
Graduation
Name of Institution
Address of Institution (city, state, ZIP code)
From
To
Degree
Date
S.I.T. CERTIFICATIONS
REGISTRATION
3
REGISTRATION BASIS (check)
WRITTEN EXAM HOURS
L.S. REGISTRATIONS
VALID
Education &
Date
S.I.T.
Registration
State
Date
Date
Comity
Exam
Survey Fund.
Survey Practice
Experience
Expired
L.S.
Number
Reference forms are attached from 5 persons listed below. Favorable replies must be received from at least 3 registered land surveyors prior to action
upon this application. References should have personal knowledge of your experience and/or ability to qualify. Providing references with up-to-date
personal information will enable objective, confidential evaluations by the board. DO NOT submit the name of an Indiana board member as a reference.
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REFERENCES
Acquaintance,
Reference
Current Address
Employer,
Name of Reference
LS Number
(number and street, city, state, ZIP code)
Associate, Etc.
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PERSONAL BACKGROUND
Have you ever been convicted of: (A) an act which would constitute a ground for disciplinary sanction under IC 25-31 or (B) a felony that has a direct bearing on your ability to
practice competently?
Yes
No
Have you been denied registration or has a registration ever been revoked or suspended?
Yes
No
Have you previously applied for and or taken the SIT/LS examination in Indiana or any other state? If yes, please attach a statement identifying dates, states and any other
pertinent information.
Yes
No
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