East-West Business Center, Unit D-Suite 208
718 N. Marine Corps Drive
Upper Tumon, GU 96913
T: 671/646-3113; 646-3115
F: 671/649-9533
W: www.guam-peals.org
E: info@guam-peals.org
  APPLICATION FOR A REINSTATEMENT OF REGISTRATION -
ENGINEER & LAND SURVEYOR
 
Indicate the type of application you are making at this time: (application shall be for one profession only)
 Engineering    
     Discipline:  
 Surveying  
   
FOR BOARD USE ONLY:
 
 
I, , on this , day of 20 hereby submit my application
  Legal Name (Last, First, Middle)     Month   Year
 
  for a reinstatement of my Registration No. which expired on
     
  Renewal of my registration after its expiration was not pursued for the following reason(s):
 
 
Enclosed is the applicable application fee of $120.00 payable to the: Treasurer of Guam. I further submit, as provided in the Bylaws of the Board, under oath, the following as evidence of my qualifications:
         
I am a:  U.S. Citizen  Permanent Resident Alien- Registration No.: A
   Legally admitted alien authorized to work in USA. (must submit proof of right to remain and work in USA)
     
 
Residence Address (Include Apt. No., City, State and Zip Code):   Mailing Address (If different from residence address):
 
     
Telephone No. -Daytime ()   Email Address:
     
 
I was born in , on / /    
  CITY STATE COUNTRY   MONTH   DAY   YEAR    
     
  My Social Security Number is: (Disclosure of your Social Security Number is mandatory).
  I am presently a member and recipient of: NCEES Record No.
     
 
 
  The following is a list of the states and/or jurisdictions from which I have received a license to practice engineering or land surveying: (Photocopies of certificates, or confirmation of examining Board must accompany this application).
     
  In column entitled "How Obtained", insert "a" (residence in State when law was first enacted), "b" (oral examination), "c" (written examination), "d" (reciprocity), "e" (education and experience), as applicable.
 
STATE BRANCH DATE GRANTED LIC NO. HOW OBTAINED
/ /
/ /
/ /
/ /
/ /
     
  In the branch of engineering or land surveying for which I am reapplying, I consider myself, by reason of training and experience, proficient in the following specialties:
 
     
  Select either yes or no and provide detailed explanation and supporting documents if applicable:
 
1. Have you ever applied for or been licensed as an Engineer or Surveyor on Guam? YES  NO
  If YES, indicate the month and year granted, or License No.    
2. Has any license ever been suspended, revoked or otherwise subject to disciplinary action?  YES  NO
  If YES, explain the type of disciplinary action    
3. Are there any disciplinary actions pending against you?  YES  NO
  If YES, explain the type of disciplinary action    
4. Have you ever been convicted of a criminal offense (except minor traffic violations with less that a $500.00 fine)  YES  NO
  If YES, explain the type of conviction    
5. In the past 10 years, have you been convicted of a crime in which the conviction has not been annulled or expunged?  YES  NO
  If YES, explain the type of conviction    
         
I am a member in good standing of the following professional organizations:
ORGANIZATION
 ADDRESS
 POSITION TITLE
 
  WORK EXPERIENCE RECORD
  My present and/or last engagement in the practice of engineering or land surveying is as follows. (Additional sheets may be used, as necessary, to describe your complete experience record provided that the information is in this format).
 
 Name of Employer:
 Dates (Mo/Yr) From: To:
 Total Time:
   Name of Immediate Supervisor:
 Address of Employer:
  Title of Immediate Supervisor:
 Address of Immediate Supervisor (if different from above):
  Type of Registration Number:
 SUMMARY OF ENGAGEMENT:
   
 
   
  IMPORTANT: This application shall be submitted on the printed form of the Board, attested before a Notary Public, accompanied by an endorsed 2"x2-1/2" photograph of the applicant.
 
 
  The above photograph shall be an unmounted recognizable photo (size 2"x2 1/2" overall), not profile, not retouched, taken within thirty (30) days of submission of this application. Affix your signature and date on the lower right hand of the photo.
   
   
  AFFIDAVIT OF APPLICANT
   
  I, , certify that the statements, answers and representations made in this application and documents attached are true and correct. I understand that any misrepresentation is grounds for refusal or subsequent revocation of my registration.
   
   
   
 
DATE SIGNATURE
   
   
  SUBSCRIBED AND SWORN to before me this day of 20 .
   
   
 
 
  NOTARY PUBLIC
   
   
 
(SEAL) My commission expires:
   
   
   
 
ALL COMITY APPLICANTS MUST COMPLETE THE FOLLOWING AFFIDAVIT - (F2)
(Territory)(State)(etc.) )
  ) ss
(Village) (City) (etc.) )
            (Applicant's Name) being first duly sworn, upon oath or affirmation, does hereby depose and say:

            I do hereby apply to the Guam Board of Registration for Professional Engineers, Architects and Land Surveyors (PEALS Board) for licensure by Comity to practice the profession of (engineering), (architecture), (landscape architecture), (land surveying) in Guam.

            I have read this application, including the instructions, and my complete answers and, the same are full, true and complete in all respects and I have completed such answers, and provided such information without mental reservation or purpose of evasion. I fully realize that the determination of whether I am allowed to practice the profession of (engineering) (architecture) (landscape architecture) (land surveying) in Guam depends on the truth and completeness of my answers in this application and the information furnished with it;

            I understand that if I have furnished significantly false or incomplete information, my application may be summarily rejected. I also understand that my obligation to furnish complete and accurate information in connection with this application is a continuing one, and accordingly, should anything occur or be discovered between the time this application is submitted and the time I am admitted which would change or render incomplete any portion of the information furnished in or in connection with this application, I will promptly notify the PEALS Board of the disrepancy, and furnish the necessary information to correct my application. I will give any further information which may be required in connection with my application;

            I have carefully read the Rules of the PEALS Board relating to the admission to practice the profession of (engineering) (architecture) (landscape architecture) (land surveying) in Guam, and I make this application in accordance to those rules;

            I hereby authorize the PEALS Board, or any agent or authorized representative thereof, to make a complete investigation of my character, financial responsibility, and general fitness to practice the profession of (engineering) (architecture) (landscape architecture) (land surveying) in Guam. I release, discharge, and exonerate from any liability whatsoever the PEALS Board, its members, employees, agents, representatives, attorneys, and any person, agency, or organization supplying requested information in connection with this application or the investigation.

            I understand that the information furnished in, and in connection with, this application is confidential and will not be disclosed to persons outside of the PEALS Board, its members , employees, agents, representatives attorneys unless required by law, without my prior consent; and that such application is and shall remain the property of the PEALS Board.

            If I am granted licensure by Comity to practice the profession of (engineering) (architecture) (landscape architecture) (land surveying) in Guam, I understand and agree that I will be bound by the bylaws, rules and regulations propounded by the PEALS Board.
   
    Applicant
     SUBSCRIBED AND SWORN to before me this day of 20 .
 
       
(SEAL) Notary Public in and for
  My commission expires:
 
 
AUTHORIZATION AND RELEASE - (F2)
(Territory) (State) (etc.) )
  ) ss
(Village) (City) (etc.) )
TO:
 
 
             I, , born at (village/city) (territory/state) , (country) having filed an application to the Guam Board of Registration for Professional Engineers, Architects and Land Surveyors (PEALS Board) for licensure by Endorsement or Comity to practice the profession, and to have an investigation made as to my moral character, professional reputation and fitness for the practice of the profession of (engineering) (architecture) (landscape architechture) (land surveying) in Guam, based upon such information as may be received by and reported by the PEALS Board. I agree to give any information which may be required in reference to my past record. I understand that the contents of my character report are privileged.

             I also authorize and request every person, firm, company, corporation, governmental agency, court, association, or institution having control of any documents, records, and other information pertaining to me to furnish to the PEALS Board and their agents and representatives, any such information, including documents, records, professional association files regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, and to permit the PEALS Board, its members, employees, agents, representatives, attorneys, and any person or organization supplying requested information in connection with this application or the investigation to inspect and to make copies of such documents, records, and other information.

             I hereby request and authorize the PEALS Board, its members, employees, agents, representatives, attorneys, and any person or organization supplying requested information in connection with this application or the investigation to request and to obtain the record of each period of my services in the Armed Forces; I further request and authorize every agency of the Armed Forces to furnish the character of my service rendered for each period. My Social Security Number is: .

             I release, discharge, and exonerate whatsoever the PEALS Board, its members, employees, agents, representatives, attorneys, and any person, agency, or organization from any and all liability of every nature and kind arising out of the furnishing, disclosure, or inspection of such documents, records, and other information of the investigation made by the PEALS Board.

             I have read my application to the PEALS Board and have answered all questions fully and frankly. The answers are complete and are true of my own knowledge.
   
    Applicant
     SUBSCRIBED AND SWORN to before me this day of 20 .
 
       
(SEAL) Notary Public in and for
  My commission expires: