Tax Payer Status Affidavit / Identity Form - Department Of Business Regulation

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For Office Use only:
Check#__________
Date:_______ Amt.____
State of Rhode Island and Providence Plantations
DEPARTMENT OF BUSINESS REGULATION
BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS
1511 Pontiac Avenue, Bldg. 68-2
Cranston, Rhode Island 02920
Tel: (401) 462-9592 Fax: (401) 462-9532 Website:
Renewal Expiration Date: 06/30/15
Renewal Fee: $300 BIENNIAL RENEWAL (2years)
Penalty Fee $60 PER YEAR IF RECEIVED AFTER JUNE 30, 2015
Indicate registration number on check
Make checks payable to: General Treasurer, State of RI
Address Change:
RI PE Registration #:____________________________________
Name: ________________________________________________
Address: ______________________________________________
______________________________________________________
Phone: (
)___________________________________________
Email address: __________________________________________
It is your responsibility to keep the Board apprised of all address and phone number changes.
Have you been the subject of a formal or informal hearing or inquiry, complaint, or disciplinary action related to
your license to practice engineering in any state since your last renewal?
YES
NO
If yes, please briefly explain and indicate the jurisdiction on an attachment.
RENEWALS and PAYMENTS POSTMARKED AFTER JUNE 30, 2015 SUBJECT TO PENALTY
The amount to be paid for the renewal of a licen se AFTER the date of expiration shall be the annual fee of one-
hundred and fifty dollars ($150) times the number of years the applicant has been delinquent, plus a penalty of
sixty dollars ($60) per year delinquent. In the event renewal is not made before the end of the third year, the
Board may require such re-examination as it deems appropriate
Registration shall be effective only from and after receipt by the Board of all such amounts as may be due.
I have read carefully the questions in this application and have answered them completely, without reservations of
any kind, and I declare under penalty of perjury that my answers and all statements made by me herein a re true
and correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute
cause for denial, suspension, or revocation of my registration in the State of Rhode Island. I understand that this
is a continuing application and that I have an affirmative duty to inform the Board of Registration for Professional
Engineers of any change in the answers to these questions after this application is signed.
Signature of Applicant: ____________________________________________
Date: _______________
Revised 2/15

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