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 TO PRACTICE - ENGINEER & LAND SURVEYOR (F1)
 
Indicate the type of application you are making at this time: (application shall be for one profession only)
 Engineering Intern  Surveying Intern
 Engineering  Surveying
       
   Discipline:
 
Application for registration via:
 Education, Experience and Examination
 Experience and Examination
 Education and Examination
 Comity (Out-of-State). NCEES Record No.
 Temporary Permit (Engineers Only)
       
FOR BOARD USE ONLY:
 
 
I, , on this , day of 20 hereby submit my application for the above
  Legal Name (Last, First, Middle)     Month   Year
 
  profession. 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 hold a valid certificate as an Engineer Intern/Land Surveyor Intern obtained by passing a written examination:
  State/Jurisdiction: Number: Date Issued: / /
     
 
 
  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 applying, 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 standingof the following professional organizations:
ORGANIZATION
 ADDRESS
 POSITION TITLE
 
   
  List five (5) references, the first three (3) of which shall be licensed or registered in the profession for which you are applying, and, if engineering, shall be licensed/registered in the branch of engineering specified on your application. These people must have personal knowledge of your professional experience, qualifications, and moral character. (if you are applying as Engineer Intern of Land Surveying Intern, three (3) character references will suffice):
 
 (1) Name
  Professional Title
  Name of Organization
  Mailing Address
 (2) Name
  Professional Title
  Name of Organization
  Mailing Address
 (3) Name
  Professional Title
  Name of Organization
  Mailing Address
 (4) Name
  Professional Title
  Name of Organization
  Mailing Address
 (5) Name
  Professional Title
  Name of Organization
  Mailing Address
     
  EDUCATION
 
NAME AND LOCATION OF SCHOOL DATES (MO/YR) DATE GRADUATED DEGREE RECEIVED
FROM TO
         
Other College/University        
NAME AND LOCATION OF SCHOOL DATES (MO/YR) DATE GRADUATED DEGREE RECEIVED
FROM TO
 
  WORK EXPERIENCE RECORD
  Number each engagement in order, beginning with your present engagement in the practice of engineering or land surveying. Summarize each engagement, but provide sufficient detail to signify the degree of your responsibility and the nature of the decisions you have been required to make. Also, indicate that you have had the progressive experience under the direct supervision of a registered engineer or land surveyor, of a grade and character which indicate that you are competent to be licensed. (Additional sheets may be used, as necessary, to descrive your complete experience record provided that the information is in this format).
   
 
 Engagement No.  Dates (Mo/Yr) From: To:
 Total Time:
 Name of Employer:
 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:
   
 
 Engagement No.  Dates (Mo/Yr) From: To:
 Total Time:
 Name of Employer:
 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:
   
 
 
  WORK EXPERIENCE RECORD
  Number each engagement in order, beginning with your present engagement in the practice of engineering or land surveying. Summarize each engagement, but provide sufficient detail to signify the degree of your responsibility and the nature of the decisions you have been required to make. Also, indicate that you have had the progressive experience under the direct supervision of a registered engineer or land surveyor, of a grade and character which indicate that you are competent to be licensed. (Additional sheets may be used, as necessary, to descrive your complete experience record provided that the information is in this format).
 
 Engagement No.  Dates (Mo/Yr) From: To:
 Total Time:
 Name of Employer:
 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:
   
 Engagement No.  Dates (Mo/Yr) From: To:
 Total Time:
 Name of Employer:
 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:
   
 
  The 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: