Application for Licensure

- 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 Application for Licensure Applicants Must Complete All Four Pages Of This Application In Ink 1 Check what you are applying for: Eligibility for admission to Part A of exam: Fundamentals of Engineering, only16 $70 LX NYS License Number Licensure 16 $377 ER 2 Social Security Number(Leave this blank if you do not have a Social Security Number) Date Issued 3 Birth Date Month Day Year Initials 4 Print Name Exactly As You Wish It To Appear On Your License 6 Telephone/E-Mail Address Last Daytime Phone: Home or Business First Area Code Phone NumberMiddle E-Mail Address (Please print clearly): Licensee business address, phone and e mail address are public information.

I am: A. A United States citizen or National. B. An alien lawfully admitted for permanent residence in the United States. C. An alien granted asylum under Section 208 of the Immigration and Nationality Act.

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