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SECTION II: CERTIFICATION OF LICENSURE/EXAMINATION

INSTRUCTIONS TO LICENSING AUTHORITY OFFICIAL: Complete Section II, sign this form, and mail it directly to the Office of the

Professions at the address at the end of this form.

Print or type the name of the applicant in the exact form in which engineering registration was issued: (If different from name in Section I)

______________________________________________________________________________________________________________________

Record of Examination.

For Fundamentals of Engineering: (Check One)

Written Examination in your state.

Hours __________ Grade __________ Date _______ / _______ / _______

NCEES exam?

Yes

mo.

day

yr.

Endorsement of examination taken in another state or territory.

Waiver of written examination based on: (Check all that apply)

Accredited engineering degree.

Oral examination.

Hours __________ Date _______ / _______ / _______

mo.

day

yr.

Demonstrated proficiency in engineering over a period of __________ years.

Other (Specify): _____________________________________________________________________________________

For Principles and Practice of Engineering: (Check One)

Written Examination in your state or territory.

Discipline: _________________________________

Hours __________ Grade __________ Date _______ / _______ / _______

NCEES exam?

Yes

mo.

day

yr.

Endorsement of examination taken in another state or territory State or territory: __________________________________________

Waiver of written examination based on: (Check all that apply)

Oral examination.

Hours __________ Date _______ / _______ / _______

mo.

day

yr.

Demonstrated proficiency in engineering over a period of __________ years.

Other (Specify): ________________________________________________________________________

If the applicant holds a current license to practice engineering in your state, what is his/her:

Expiration date of

License number ______________________ Date issued __________________________ most recent registration ______________________

Was there ever any disciplinary action against this license?

YES

If so, please explain _______________________________________________________________________________________________

Are any disciplinary charges pending against this license?

YES

If so, please explain _______________________________________________________________________________________________

ATTESTATION

I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this form. I further

certify that, other than those listed above or in attached correspondance, 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 to

the licensing authority relating to any question of unprofessional or immoral conduct except as noted in question 3 above.

Signature ______________________________________________________________ Date _____________________________

Print name ____________________________________________________________

Title __________________________________________________________________

(LICENSING AUTHORITY

Agency _______________________________________________________________

SEAL)

Address _______________________________________________________________

Telephone __________________________ Fax number ________________________

E-mail ________________________________________________________________

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

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

Professional Engineering Form 3, Page 2 of 2, June 2004