Application for Professional Engineer, Professional ...

1 Bureau of Professional Licensing PO Box 30670 Lansing, MI 48909 Telephone: (517) 241-9288 Professional ENGINEER, Professional SURVEYOR, ORARCHITECT RELICENSURE Application (This Form Should Not Be Used For License Renewal) Authority: 1980 PA 299, MCL Legal Name (First, Middle, Last)Date of Birth Social Security Number Address City State Zip Code Permanent Number Telephone Number E-Mail AddressI have the ability and will serve the public in a fair, honest and open manner. If I have had a judgment of guilt in a criminal proceeding or a civil action against me, I am rehabilitated or the substance of my former offense is not reasonably related to the occupation or profession for which I am seeking a license. Yes No Do you have any unsatisfied penalties or conditions imposed by disciplinary action in this state or any other jurisdiction? Yes No Applicants whose license has been expired for LESS than 3 yearsArchitect: Submit proof of not less than 24 hours of continuing education that was completed during the 2-year period immediately preceding the date of relicensure.

2 The continuing education must be in activities approved under administrative rule R and must cover health, safety, and welfare subjects approved under administrative rule R Engineer and Professional Surveyor: Submit proof of completing not less than 15 hours of continuing education that was completed during the 12 months immediately preceding the date of the Application for whose license has been expired for MORE than 3 years Architect, Professional Engineer and Professional Surveyor: Must meet all of the applicable education, examination, and experience requirements currently required for licensure under MCL and administrative rules promulgated by the department. The applicant must produce the records required for demonstrating he or she satisfies the current requirements at the request of the department. Architect relicensure applicants must submit proof of not less than 24 hours of continuing education that was completed during the 2-year period immediately preceding the date of relicensure.

3 The continuing education must be in activities approved under administrative rule R and must cover health, safety, and welfare subjects approved under administrative rule R I certify that the statements in this document are true and complete. I understand that any omitted statement, misrepresentation, or fraud may be cause for denial of my Application , disciplinary action, or may be punishable by law. I agree the Department is required by law to obtain my social security number pursuant to MCL Signature Date CHECK THE LICENSE/REGISTRATION TYPE FOR OFFICE USE ONLY Professional Engineer Relicensure $ Professional Surveyor Relicensure $ Architect Relicensure $ 6201-06 4001-06 1301-06 License Number Issue Date Make your check or money order in Currency payable to: STATE OF MICHIGAN FEES ARE AUTHORIZED BY THE STATE LICENSE FEE ACT, 1979 PA 152 AND ARE NOT REFUNDABLE. LARA/BPL-DBRELIC (Rev.)

4 03/20) The Department o f Licensing and Regulatory Affairs will not discriminate against any individual o r group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under t he Americans with Disabilities Act, yo u may mak e your needs known to this agency.