Professional Engineering - Application For Licensure And First Registration - The University Of The State Of New York The State Education Department - 2011

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The University of the State of New York
Department Use Only
Professional Engineering
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 1
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
Application for Licensure and First Registration
Applicants Must Complete All Four Pages Of This Application In Ink
1
Check what you are applying for:
NYS License Number
Eligibility for admission to Part A of exam: Fundamentals
EI
$70
ER
of Engineering, only
Licensure
16
$377
ER
Date Issued
Social Security Number
2
Initials
(Leave this blank if you do not have a U.S. Social Security Number)
3
Birth Date
6
Month
Day
Year
Telephone/E-Mail
4
Daytime Phone
Print Your Name Exactly As You Wish It To Appear On Your License
Last
Phone Number
Area Code
First
Middle
Extension
E-Mail Address (Please print clearly)
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
7
I am applying for (check all that apply):
Office
use only
Eligibility for admission to examination(s):
Part A: Fundamentals of Engineering
Part B: Principles and Practice of Engineering
Licensure by endorsement of examinations (use Form 3) :
Check if using NCEES Record
Transfer of examination grade(s) from other state(s) or U.S. Territory(ies) (Use Form 3)
Part A: From State/territory of ___________________________________________
Exam date: _______ / _______ / _______
No. of hours: __________
Part B: From State/territory of ___________________________________________
Exam date: _______ / _______ / _______
No. of hours: __________
8
Have you previously applied for New York State professional licensure ?
YES
NO
If yes, what profession(s) _______________________________________________________________________________
9
Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or
YES
NO
misdemeanor) in any court?
YES
10
NO
Are criminal charges pending against you in any court?
Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted
11
YES
surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or
NO
previously, or ever fined, censured, reprimanded or otherwise disciplined you?
12
Are charges pending against you in any jurisdiction for any sort of professional misconduct?
YES
NO
NOTE: If you answer "Yes" to any questions numbered 9-12, submit a letter giving a complete detailed explanation. Include copies of any court
records (conviction records), and if you possess one, a copy of the “Certificate of Relief from Disabilities” or your “Certificate of Good Conduct.”
Professional Engineering Form 1, Page 1 of 4, Rev. 4/11

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