ARCTIC REQUIREMENT (See 12 AAC 36.110) FOR ENGINEERING APPLICANTS ONLY:
Board-approved arctic engineering university-level course completed or in progress:
Date:
College:
GENERAL INFORMATION QUESTIONS - (AS 08.48.111)
Have you:
YES
NO
1. had any felony convictions relating to the profession for which you are applying?...................................
2. had any professional society revocations? ...............................................................................................
3. had any license actions or been denied renewal in any jurisdiction? .......................................................
4. had the right to practice before any state or federal agency denied, suspended, or revoked? ................
5. been found guilty of misconduct, dishonesty, fraud, incompetence, and/or gross negligence in the
practice of Engineering or Land Surveying?.............................................................................................
If the answer is yes to any of the above questions, submit a written explanation with your application.
All information provided with your response will be considered public information unless required to be kept confidential by state or
federal law.
RULES OF PROFESSIONAL CONDUCT
I hereby certify that I have read the Alaska Statutes Section 08.48 and Professional and Vocational Regulations Title 12, Chapter 36,
Alaska Administrative Code and agree to abide by the rules of professional conduct as set forth therein.
APPLICANT SIGN HERE
Signature of Applicant
AFFIDAVIT
STATE OF
)
) ss.
Borough-County of
)
, being duly sworn, deposes and says: I am the applicant named in this
(Name of Applicant)
application, have read the contents thereof and, to the best of my knowledge and belief, the foregoing statements are true and correct
in every respect.
Subscribed and sworn to before me this
day of
,
.
APPLICANT SIGN HERE
Signature of Applicant
(IN PRESENCE OF NOTARY)
NOTARY SIGN HERE
Signature of Notary Public
My Commission Expires:
08-4085 (Rev. 11/00)
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