Application for Licensure - New York State …

- 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.

2 NO Birth Date - Professional Engineering . The University of the State of New York . Department Use Only . THE STATE EDUCATION DEPARTMENT . …

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