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Form Aels - Application For Opening A File For Retention Of Land Surveyor Work Verification Forms - Alaska Department Of Community And Economic Development

AELS

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

BOARD OF REGISTRATION FOR ARCHITECTS, ENGINEERS AND LAND SURVEYORS

P.O. BOX 110806, JUNEAU, ALASKA 99811-0806

(907) 465-2540

E-mail: license@dced.state.ak.us

APPLICATION FOR OPENING A FILE FOR RETENTION

OF LAND SURVEYOR WORK VERIFICATION FORMS

APPLICANT

(AS PROVIDED FOR IN 12 AAC 36.066)

FILE NUMBER:

DIRECTIONS:

FEE: $50

Read Statutes and Regulations.

Type the application. Handwritten applications will be returned.

Read items 1–8 at bottom; sign and date on the indicated lines.

Submit the application and fee ($50) check or money order payable to the State of Alaska – to the Juneau office

at the address above.

THIS IS NOT AN APPLICATION FOR EXAMINATION OR REGISTRATION.

Title (Optional):

Mr.

Ms.

Mrs.

Maiden Name (if applicable):

Name:

Last

First

Middle Name or Initial

Mailing Address:

Street or P.O. Box

City

State

Zip Code

Physical Address:

Street

City

State

Zip Code

Date of Birth:

Social Security Number (Optional):

Home Telephone Number: (

)

Work Telephone Number: : (

)

E-mail Address (Optional):

Fax Number (Optional):

By my signature below, I acknowledge and agree to the following:

I have read all applicable statutes and regulations, including 12 AAC 36.066 on the reverse side.

This is an application to open a file for retention of land surveyor work verification forms; it is NOT an application

for examination or registration.

The Department will maintain this file for a period of five (5) years from the date the application and fees are

received in the Juneau office.

Before the end of the five-year period, I may submit a new application and applicable fees and request the

Department to maintain the file for an additional five years.

It is my responsibility to reapply before the end of the five-year term; the Department will NOT notify me in

advance of the file termination date.

Work verification forms submitted for this file will not be reviewed by the staff or the board until I submit a

complete application and all fees for land surveyor registration by comity or examination.

All work verification forms must be submitted directly to the Department by my employers or supervisors, and

must be on a form prescribed by the board.

The $50 fee is nonrefundable and may not be applied to any registration or examination fees.

Applicant’s Signature

Date

08-4412 (New 11/99)

Form Aels - Application For Opening A File For Retention Of Land Surveyor Work Verification Forms - Alaska Department Of Community And Economic Development

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