9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

Louisiana Professional Engineering and Land Surveying Board

Application for Licensure as a Professional Surveyor by Examination

INSTRUCTIONS

NOTE: Applications are subject to revision and modification at any time. In order to ensure timely processing, please verify that you are submitting the most current version of our application form (see www.LAPELS.com).

• Read all of the instructions before you begin. • Applications must be typed (hand written applications are not acceptable) • Exam applications & all supporting documents must be received by the LAPELS application

deadline. • Complete all required sections of the application; incomplete applications will not be processed. • After you have completed the application, please mail it to LAPELS, 9643 Brookline Avenue, Suite

121, Baton Rouge, LA 70809. Make check or money order payable to LAPELS, or complete the credit card authorization form provided.

In addition to the Application as a Professional Surveyor by Examination, please also submit the following which you will find under “Supporting Document Forms for Applications”:

• Personal Reference Forms • Verification of Experience Forms • Laws and Rules Quiz, Professionalism & Ethics Quiz and Louisiana Standards of Practice for

Boundary Surveys Quiz – Complete the Online Laws and Rules, the Online Professionalism & Ethics and the Online Louisiana Standards of Practice for Boundary Surveys quizzes here. You and the LAPELS staff will receive an email confirmation once you have achieved a minimum score of 90%.

• Surveyor Course Evaluation Form (unless previously submitted with LSI application) • Transcript Request Form (send to university OR request Escripts addressed to

transcripts@lapels.com) • Verification of Licensure/Certification/ Examination

Surveyor Course Evaluation form – complete the form - 30 semester credit hours must include a minimum of 15 semester credit hours in Surveying courses of which 3 semester credit hours must be a Boundary Surveying course, a minimum of 3 semester credit hours in Mapping courses and 3 semester credit hours in Real Property courses. If the courses you have taken are not on our approved list (see website), you must submit syllabi for those courses with your application.

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

Section 1 – Personal Information Open the appropriate application and complete all fields, entering your full legal name and

social security number. Louisiana Revised Statute 37:23 requires that every application by an individual for a professional license, permit or certificate shall require the applicant’s social security number. Disclosure of your social security number is mandatory for this purpose and for purposes of establishing, modifying or enforcing family and child support obligations and locating an individual who is under an obligation to pay family or child support under La. R.S. 46:236.1.1, et seq. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure, permit or certificate application. Disclosure of your social security number is voluntary for disclosure to other state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional regulation. Such disclosure is for identification purposes only. Your social security number will not be released for any other purpose not provided by law.

• Enter dates using this format: MM/DD/YYYY • Do not leave any section blank. State ‘N/A’ where applicable • Provide a phone number and email address where you can be reached during the day.

Section 2 – Education – indicate ALL colleges/universities attended where a degree was conferred or is in progress, or where you have completed surveying coursework.

• Transcript Request form – after completing the appropriate fields, print this form and send on to each college/university you attended. Transcripts must be submitted directly to LAPELS by the college/university per LAPELS per §Rule 1701.C. (send to university, or request EScripts addressed to transcripts@lapels.com). Transcripts which have been issued to the applicant in an envelope sealed by the university will be rejected by LAPELS.

• NCEES Dashboard – If you have an NCEES dashboard that contains this information, no further action is needed.

Section 3 – Examination and Licensure/Certification in Louisiana and Other Jurisdictions - Provide Surveying Intern information, and FS exam information, and answer questions regarding residence & multiple exam attempts.

• Verification of Licensure/Certification/Examination – from state licensing boards where you were FIRST certified and licensed. If your original license is inactive, please also provide verification of active licensure.

• Online Verification Process – If you have an NCEES account, you will need to login to your “MyNCEES” and request the electronic verification there. If you do not have an account, it is free to sign up and you can begin your electronic verification submittal. We have listed the States that participate in online verifications with NCEES on the LAPELS website under “verifications”.

• NCEES Dashboard – If you have an NCEES dashboard that contains this information, no further action is needed.

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

• Manual Verification of Licensure/Examination Form – Use ONLY if the State where you are licensed does not participate in the electronic verification.

Section 4 – Personal References – list those individuals you have asked to provide personal references.

• Personal Reference Forms – after completing the appropriate fields, print five (5) forms and send a form and instructions to personal references to those you have selected to provide a personal reference for you. Personal Reference forms should be returned to you in a signed/sealed envelope and included with your application for submittal to LAPELS. These forms are confidential and should not be opened by the applicant.

• Applications for licensure as a professional engineer or professional land surveyor shall be completed on the most current forms developed by the board. The application shall contain statements showing the applicant's qualifications, and the names and addresses of five personal references. None of the five personal references can be an immediate family member or business associate of the applicant. For purposes of this §1701.B, immediate family member is defined as a spouse, child, spouse of a child, sibling, spouse of a sibling, sibling of a spouse, parent, parent of a spouse, stepparent or stepchild. For purposes of this §1701.B, business associate is defined as a subordinate of the applicant, or a consultant or contractor who provides goods or services to the applicant or to a business, entity or agency in which the applicant is an owner, member, officer, director, trustee, partner, principal, manager, employee, associate, consultant or contractor. Three or more of the five personal references furnished by an applicant for licensure as a professional engineer shall be professional engineers holding valid licenses to engage in the practice of engineering issued to them by proper authority of a state, territory, or possession of the United States, or the District of Columbia. Three or more of the five personal references furnished by an applicant for licensure as a professional land surveyor shall be professional land surveyors holding valid licenses to engage in the practice of land surveying issued to them by proper authority of a state, territory, or possession of the United States, or the District of Columbia....

Section 5 - Violations – if you answer yes to any of these questions, you must submit a detailed description for each violation. Use extra pages if necessary. Section 6- Acknowledgement – – print, sign and date or you may also sign using the digital signature.

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

Section 7 – Experience Record Summary – You must include a GRAND TOTAL of all experience on this page. APPLICATION IS INCOMPLETE WITHOUT THESE GRAND TOTALS.

• Experience Record Forms - see instructions on form

• Verification of Experience Form – after completing the appropriate fields, ensure that the “From” and “To” dates, name, title and present address of person most familiar with each engagement match the information on the Experience Record forms. Send a Verification of Experience form and copy of Experience Record which that person will verify, to each supervisor listed on the Experience Record forms. Verification of Experience Forms should be returned to you in a signed/sealed envelope and included with your application for submittal to LAPELS. These forms are confidential and should not be opened by the applicant.

It is your responsibility to submit a complete and accurate application, which includes the required/non-refundable application fee of $50 (check, credit card authorization, or money order only). Upon receipt of your application, the Board applications staff will process your paperwork and communicate with you concerning any missing or incomplete documentation. Once your application is complete, it will be forwarded to a Board reviewing committee. Processing time for a complete application is 6-8 weeks.

A letter will be mailed to you from LAPELS informing you of approval or disapproval.

ApplicationCheckListCoverSheet

ApplicantName:

LastfourofSSN: Included Requested

RequiredDocumentsCurrentApplication

Check,CreditCardAuthorizationFormorMoneyOrder

Transcripts

CredentialEvaluation(onlyforforeign/NONABETdegrees)

VerificationofFundamentalsExam&Certification

PersonalReferences

ExperienceRecordForms

VerificationofExperienceForms

SurveyorCourseEvaluationForm

Laws&RulesQuiz(submittedonline)Professionalism&EthicsQuiz(submittedonline)StandardsofPracticeforBoundarySurveysQuiz(submittedonline)

PleasecheckoneApplicantNotes

Comments:

RequiredOnlineApplicationQuizzes completed‐achieved90%orbetter

Louisiana Professional Engineering and Land Surveying Board

Application for Licensure as a Professional Surveyor by Examination

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

Applying under the provisions of La. R.S. 37:693(B)(4)(a): Examination

A $50 non-refundable fee is to be submitted with this application. Make checks or Money Order payable to LAPELS, or you may use the credit card authorization form. Do not leave any section blank and state “not applicable” or “none” if such is the case. ALL INFORMATION MUST BE TYPED. Hand written applications are not acceptable.

Date of application: MyNCEES #

1. PERSONAL INFORMATION

SSN: Name: Last Name First Name Middle/Maiden Name Suffix

Address:

City: State: Zip: Country:

Work Phone: Home/Cell Phone: E-Mail:

Date of Birth: City of Birth:

State of Birth:

Country of Birth:

Gender: US Citizen? Yes No If no, what country? Visa/Green Card #:

2. EDUCATIONList in chronological order, the name and location of each college or university where a degree was conferred or is in progress or where you have completed surveying coursework, the time spent at each institution, and if graduated, the date of graduation, the degree received and the major as shown on your transcript. See the instructions concerning submitting transcripts and if applicable, a credential evaluation. Transcripts must be submitted by your college/university directly to LAPELS

Institution Information Years Attended Graduation Date

Degree Received and

Major Type Name State From - To

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

3. EXAMINATION AND LICENSURE/CERTIFICATION IN LOUISIANA AND OTHER JURISDICTIONSJurisdiction Date Basis of License

First PS License NCEES Exam Other: (explain):

Fundamentals (FS/LSI) Exam No. of hours Certificate No.

Principles and Practice (PS) Exam No. of hours License No. What state did you reside in one (1) year prior to taking the FS?

If you made multiple attempts at this exam, list your number of attempts and jurisdictions:

Number of Attempts Jurisdiction

Number of Attempts Jurisdiction

Number of Attempts Jurisdiction

What state did you reside in one (1) year prior to taking the PS?

If you made multiple attempts at this exam, list your number of attempts and jurisdictions:

Number of Attempts Jurisdiction

Number of Attempts Jurisdiction

Number of Attempts Jurisdiction

4. PERSONAL REFERENCES (5 references, 3 must be actively licensed Professional Surveyors. See rulechange 1701.B, effective 12/2015)

Name Mailing Address City State Zip

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

5. VIOLATIONSHave you ever been convicted of a felony or of a crime of moral turpitude or entered a plea of guilty or nolo contendere to a felony charge or to a crime of moral turpitude under the laws of the United States or any state, territory or district of the United States?

Mark one: Yes No

Have you ever been convicted of any crime or entered a plea of guilty or nolo contendere to any criminal charge an element of which is fraud or which arises out of your practice of engineering or surveying? Mark one: Yes No

Have you ever been convicted of any civil or criminal violation of, or entered a plea of guilty or nolo contendere to any criminal charge under, the Louisiana Campaign Finance Disclosure Act or any other campaign finance and/or practices laws of the State of Louisiana, the United States, or any state, territory or district of the United States? Mark one: Yes No

If you have a license, permit or certificate to practice engineering or surveying, has it ever been the subject of a disciplinary action by any state, territory or district of the United States? Mark one: Yes No N/A

Are you an owner, partner, officer, director, managing member or supervising professional of a firm whose license, permit or certificate to practice engineering or surveying has ever been the subject of a disciplinary action by any state, territory or district of the United States? Mark one: Yes No

If the answer to any of these questions is “Yes”, provide the date and the pertinent facts of the case or proceeding including its final disposition. Attach additional pages as necessary.

DISCLOSURE As part of the application process, the Louisiana Professional Engineering and Land Surveying Board (LAPELS) will obtain a consumer report, which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living.

AUTHORIZATION During the application process and at any time during the tenure of my licensure with LAPELS, I hereby authorize LexisNexis WorkPlace Solutions Inc., on behalf of LAPELS, to procure a consumer report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit bureaus, court record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification and a written summary of consumer rights; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

_________________________________________________________ Applicant Signature Date

Print Name Date of Birth *

Social Security Number *

* For Identification Purposes Only

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

6. ACKNOWLEDGMENT I, the applicant named in this application, have read the contents hereof, and to the best of my knowledge, information and belief the statements and information in this application are true and correct in substance and effect and are made in good faith. I have not omitted any information requested in this application. I am aware that such an omission or untrue response may constitute fraud or deceit, material misstatement, perjury or the giving of false or forged evidence under Louisiana Revised Statutes 37:698 and 37:700. I understand and agree that any responses verifying my education, personal references, and experience shall be considered privileged and confidential and that this information was not reviewed by me nor will it be available for my inspection or review in the future. I have read the Rules for Professional Engineers and Surveyors (LAC Title 46, Part LXI), and I agree to conduct my professional affairs in accordance with these rules.

Signature of Applicant:

For LAPELS office use only – do not write in this area

Payment Type: Check # Credit Card Confirmation #

Money Order #

Application

CAVU

Payment Amt. NCEES

Background

INSTRUCTIONS FOR COMPLETING EXPERIENCE RECORD FORMS

ALL SURVEYING EXPERIENCE AND ALL TIME SINCE GRADUATION WITH BS DEGREE MUST BE DOCUMENTED ON AN EXPERIENCE RECORD FORM. You must include military, illness, unemployment or time spent completing an additional college degree, etc., on an Experience Record form. Time gaps will result in an incomplete application. The chart below is an example of the 8 column Experience Record form. The instructions below indicate how to complete the information in each of the columns.

1st column: Record number (start with first employment – end with current employment) 2nd column: Start date & end date for this record. The ending date for your current employer should be the same month & year as the application date. Dates must be reflected in “mm/yyyy” format. “Current” and/or “present” are not acceptable timeframes. 3rd column:

a. Position titleb. Company namec. Detailed description of experience (see paragraph below)*. Indicate character, magnitude & complexity of your work, yourduties & degree of responsibility. When describing experience, refer to Chapter 15, specifically Rules 1515, 1517 and 1519.Inadequate descriptions will delay the review process. Click here for additional information regarding the description of yourexperience.d. Name, title and present address of the supervisor or person most familiar with this engagement.

4th through 8th columns: List amount of time for this experience record in years & months, in the appropriate category.

*Applicant must comply with LAPELS Rule §1527 Supervision by Licensed Professional:B. Surveying. Experience should be gained under the supervision of a professional surveyor holding a valid license to engage in thepractice of surveying issued to him/her by proper authority of a state, territory, or possession of the United States, or the District ofColumbia, or, if not, an explanation shall be made showing why the experience should be considered acceptable.(You may add an explanation to the Experience Record form or include a separate note.)

EXPERIENCE RECORD EXAMPLE

Name (Last, First): Doe, John

1

(1)

01/1999 04/2013

(2)

a. Position title

b. Company name

c. Description of experience

(3)

d. Supervisor name, title & current address

Times of each employment category (years and months)

(4) (5) (6) (7) (8)

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Begin listing your experience on the forms following this page, starting with your first employment. Use the TAB key to move between shaded fields. Click here for additional pages, if necessary. Remember, you must document all time subsequent to your graduation: military, illness, unemployment or time spent completing an additional college degree, etc. Once you have completed all of your experience, tally the time for each category in the box on the last page. These totals must be completed and correspond with all time on your experience records.

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/ MODIFIED MAR 2018

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

NAME

EXPERIENCE RECORD

- a.

b.

c.

d.

Times of each employment category (years and months)

Non

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continued on next page

9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

NAME

EXPERIENCE RECORD

- a.

b.

c.

d.

Times of each employment category (years and months)

Non

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9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

NAME

EXPERIENCE RECORD

- a.

b.

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d.

Times of each employment category (years and months)

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9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

NAME

EXPERIENCE RECORD

- a.

b.

c.

d.

Times of each employment category (years and months)

Non

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9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809-1433 • (225) 925-6291 • Fax (225) 925-6292 • www.lapels.com/MODIFIED MAR 2018

Once you have completed all of your experience, tally the time for each category in the box below. These totals must be completed and correspond with all time on your experience records.

7. EXPERIENCE RECORD SUMMARY

Name (Last, First):

Times of each employment category (years and months)

(4) (5) (6) (7) (8)

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GRAND TOTALS OF ALL EXPERIENCE: (These fields must be completed) ⇒

y

m

y

m

y

m

y

m

y

m

Credit Card Authorization Form (All information will remain confidential)

Cardholder Name:  

Name on Application:       (if different from credit card holder) 

Billing Address:   

American Express 

Phone Number:                                                           Email:        

Credit Card Type:  Visa  MasterCard  Discover 

Credit Card Number:       

Expiration Date:         (MM/YY)

Card Identification Number (last 3 digits on the back of the credit card):  

Amount to Charge (USD): $        

I authorize LAPELS to charge the agreed amount listed above to my credit card provided herein. I 

agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement. 

Cardholder: Print Name, Sign and Date below 

Signature: 

Print Name: 

Date:  

Sign and return with application.OFFICE USE ONLY 

Application Type ________________

Confirmation Number __________________