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Certificate of Authorization

RI COA# _____________

Check#______________

Initial Application

Date:_______ Amt.____

Board of Registration for Professional Engineers

1511 Pontiac Avenue, Bldg.68-2, Cranston, RI 02920

Phone: (401) 462-9592

Fax: (401) 462-9532

CHECK ALL BOXES THAT APPLY



Initial Application Fee: $150.

FEE WAIVED - No Employees

Partnership



FEE WAIVED IF NO EMPLOYEES

Corporation

Limited Liability Company



Indicate Certificate of Authorization number on check.

Sole Proprietorship

Limited Liability Partnership



Make checks payable to: Treasurer, State of RI

Name under which services will be offered:

Change of Name & Address: (If Applicable)

Name:

Address:

Type of Engineering Services Offered in R.I.: ____________________

Phone: (

) ______________

Fax: (

) ________________

PART I

List all Rhode Island licensed engineers in responsible charge who act on behalf of the firm.

If you are a Sole Proprietorship, list your name.

For the purposes of this requirement, no person who is not an employee of the firm may be considered to be in responsible charge. The engineer in

responsible charge shall work not less than twenty (20) hours per week for the firm, provided however that the Board might waive such requirement

upon written application to the Board for good cause shown.

I hereby certify under oath that I acknowledge that I have the obligation of keeping the Board informed at all times in the event that I should terminate

my employment and/or position of engineer in responsible charge. I further acknowledge that in the event that such a termination of responsibility

occurs, that I must notify the board, in writing, within seven (7) days of the date of such termination and that otherwise, the Board shall be authorized

to hold me responsible for any and all work performed by this firm.

Name

Discipline Are you listed on other COA’s in RI?

Signature

RI Lic. No.

Yes

How Many

PART II

TO BE COMPLETED ONLY IF YOU HAVE NO EMPLOYEES.

If you are the only employee in your firm, you are exempt from the fee if you complete this section.

“I hereby certify that I have no employees and that I am the sole Rhode Island licensed engineer of the firm and the individual in responsible charge.”

Signature: _____________________________________________

PART III

Have you or any partner, officer, majority shareholder or member of the Board of Directors, been convicted of or entered into a plea bargain

any offense which involves, fraud, professional negligence, moral turpitude or are any such charges now pending?

If yes, for each such offense, state the nature of the charge, the State in which the charge was brought and the person or persons convicted

or has entered into a plea. If any charges are pending, please briefly explain.

Yes _____ No _____

2. Has any officer, majority shareholder or member of the Board of Directors, or any registered P.E. employed by the firm, had his or her license to

practice engineering revoked or suspended in any State? If yes, state the name of such person, their address, and the nature and State of such

revocation or suspension.

Yes _____ No _____

3. Have you read/understood the provisions of R.I. Gen. Laws Title 5, Chap. 8 as amended?

Yes _____ No _____

4. Have you read/understood the Rules and Regulations and the Canons of Ethics adopted by the Board?

Yes _____ No _____

I am aware that the Certificate of Authorization may be revoked if any agent, employee, director or officer of the corporation violates or causes to be

violated any provisions of those laws or regulations governing the practice of engineering in RI.

Signed:___________________________________________________Title:_________________________ Date:____________________

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