STATE OF CALIFORNIA GAVIN NEWSOM, GOVERNOR

BOARD FOR PROFESSIONAL ENGINEERS, LAND SURVEYORS, AND GEOLOGISTS 2535 Capitol Oaks Drive, Suite 300, Sacramento, California, 95833-2944

Telephone: (916) 263-2222 – Toll Free: 1-866-780-5370 Facsimile: (916) 263-2246

www.bpelsg.ca.gov

Professional Geologist (PG) and Professional Geophysicist (PGP) Application Checklist

Applicants applying for the PG or PGP license are encouraged to use this checklist to ensure that they meet all application requirements. For detailed information about requirements read the Frequently Asked Questions (FAQs) Regarding Geology and Geophysics Licensure Requirements.

� Confirm that you meet the qualifying educational and experience requirements before applying by reviewing the applicable statutes and regulations: For the PG license, review Business and Professions Code section 7841 and Title 16, California Code of Regulations sections 3022 and 3023. For the PGP license, review Business and Professions Code section 7841.1 and Title 16, California Code of Regulations sections 3022.1 and 3023.

� Complete the application in its entirety. An original/wet signature is required on each page.

� Submit official, sealed college/university transcripts for all relevant degrees and coursework, including community college transcripts. Unsealed transcripts are not accepted. Foreign transcripts that are not in English do not need to be sealed, but applicants must submit the original transcripts along with a notarized English translation. Degree evaluations are not accepted.

Important Note: Applicants who have submitted transcripts with a prior application do not need to submit transcripts again unless they have completed additional education after the submittal of their prior application that they want credit for (i.e. Professional Geologist applicants who have submitted transcripts with a California Geologist-in-Training application).

� Submit a minimum of three (3) Independent Evaluation of Scope, Character and Duration of Applicant’s Qualifying Geological or Geophysical Work Experience forms (or more) to adequately document that you meet the qualifying experience requirements as indicated in the Business and Professions Code and Title 16, California Code of Regulations.

� Professional Geologist applicants that have passed the ASBOG Fundamentals of Geology (FG) and/or Practice of Geology (PG) exams in another state (after November 1, 1996) must submit a Verification of Licensure or Passage of Examinations form. The form must be completed by the appropriate state agency.

� Submit proof of completing the fingerprinting requirement, unless you have fulfilled the requirement with a prior application (i.e. Professional Geologist applicants that have fulfilled the requirement with their Geologist-in-Training application). Applicants who still need to fulfill the requirement must submit a copy of the completed Live Scan Form (applicants who reside or are currently located in California) or Fingerprint Cards (applicants who reside or are currently located outside of California). For additional information, review the Fingerprinting FAQs.

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� Certified court documents (if applicable). If you marked “yes” to any question in Section 5 of the application, you must submit certified court documents and a written statement explaining in your own words the acts or circumstances that led to the plea/conviction, unless you submitted the certified court documents with a prior application. For additional information, review the Fingerprinting FAQs.

� Submit the appropriate fees as indicated on the first page of the application. Submit a check or money order payable to the Department of Consumer Affairs (DCA).

� Put the application, all supporting documentation, and payment in one envelope (with the exception of the Verification of Licensure or Passage of Examinations form, which may be submitted directly to the Board from the other state agency). Submitting the documents separately will delay the processing of your application.

� Submit the application package postmarked by the final filing date for the desired exam cycle to:

Board for Professional Engineers, Land Surveyors, and Geologists 2535 Capitol Oaks Drive, Suite 300, Sacramento, CA 95833

� Use a mail tracking or delivery confirmation system to confirm the Board’s receipt of your application. Due to the large volume of applications received by the Board, the Board cannot confirm receipt of applications or provide status checks. Communication regarding your application status will be sent to you via email (including emails from Board staff requesting additional documentation regarding your application, and notification of application approval).

Page 2 of 2 PG and PGP Application Checklist November 2019 Version 1.0

For Office Use Only

ATS ID #

Date Rcvd.

Amount

Receipt #

FP Card Rcvd. Fee Rcvd. LS

Mil. Yes FP/LS On file

STATE OF CALIFORNIA GOVERNOR GAVIN NEWSOM

BOARD FOR PROFESSIONAL ENGINEERS, LAND SURVEYORS, AND GEOLOGISTS 2535 Capitol Oaks Drive, Suite 300, Sacramento, California, 95833-2944

Telephone: (916) 263-2222 – Toll Free: 1-866-780-5370 Facsimile: (916) 263-2246

www.bpelsg.ca.gov

APPLICATION FOR LICENSURE AS A PROFESSIONALGEOLOGIST OR GEOPHYSICIST

Application: $250 (Non-refundable)

ASBOG® Fundamentals of Geology (FG): $150

ASBOG® Practice of Geology (PG): $250

California Specific Examination (CSE): $150

Professional Geophysicist (PGp): $100

Fingerprint Cards Included (add $49) ORLive Scan Form included OR

I submitted my Live Scan Form/Fingerprint Cards with a prior application

Total Due to Board $

Note: Do not use this application if you are taking the FG exam as a Geologist-in-Training (GIT) applicant. Use the Application for Certification as a GIT.

MAKE ONE CHECK OR MONEY ORDER PAYABLE TO DEPARTMENT OF CONSUMER AFFAIRS (DCA)

Exam Cycle: Year:

Section 1

General Information Please Note: The names and addresses of Board licensees are public records and are published in both electronic and print media, as well as disclosed to the public upon request. You may use a home address, a post office box, a business address, or an alternate address where you can receive mail.

1. Last Name (note prior names in remarks section) First Name Middle Name 2. Social Security No. or ITIN

3. Address of Record: City State Zip Code Country

4. Birth Date (MM/DD/YYYY): Email Address:

5. Daytime Phone Number (including area code& extension): Ext.

Evening Phone Number (including area code): Cell Phone Number (including area code):

6. Are you licensed or registered as a Professional Geologist in any state other than California which required passing scores on the ASBOG®Fundamentals of Geology and/or the Practice of Geology examinations? Yes No (if no, skip to question 8 below)

Please note: The ASBOG® Fundamentals of Geology or the Practice of Geology examination results before November 1, 1996 will not be accepted.

7. List the states in which you took and passed any licensing examinations.

STATE EXAMINATION DATE TAKEN

If you answered yes to question 6, complete and submit a Verification of Licensure or Passage of Examinations form to the appropriate agency in the state in which you passed the exam(s) to provide verification of passing the exam(s). Verification is required from the state agency.

8. Have you previously filed an application for licensure/certification with this Board? Yes No

License Type(s): License Number(s): Date(s):I certify under penalty of perjury under the laws of the State of California that the information on this application as well as any other documents submitted in support of this application are true and correct to the best of my knowledge.

Applicant’s Signature (Wet Signature Required) Date:

USE A TYPEWRITER OR FILL OUT FORM ONLINE, PRINT, SIGN AND MAIL THIS APPLICATION TO ADDRESS ABOVE

Application for Licensure as a PG or PGp (Revised 11/2019) Version 1.0 Page 1 of 5

Applicant’s Name (Last) (First) (Middle)

Section 2-Education Section 2A-Must be completed by PG applicants who do not have a California GIT Certificate

Section 2B-Must be completed by PGP applicants PG and PGP applicants who have not previously submitted transcripts to the Board, or have new educational credit that they want considered, must request and submit sealed, certified transcripts for all relevant degrees and course work (including community college transcripts). PG applicants who have a California GIT are not required to complete this section, unless they want new educational credit considered. Do not have the school submit the transcripts directly to the Board. Submit the sealed transcripts with your application. Unsealed transcripts will not be accepted. Foreign transcripts that are not in English do not need to be sealed but a notarized translated copy of the transcripts must be submitted along with the original transcripts. Foreign degree evaluations are not accepted.

Section 2A (Education): Professional Geologist (PG) applicants complete this section The statutes and regulations include two (2) qualifying education options for the PG license: a qualifying degree OR qualifying coursework. Applicants only need to fill out the section relevant to them; either the qualifying degree OR qualifying coursework option. Refer to the FAQs Regarding Geology and Geophysics Licensure Requirements on the Board’s website for additional information.

Qualifying Degree Option for a PG license In accordance with Business and Professions Code section 7841(b)(1) and Title 16, California Code of Regulations section 3022(a)(1), a qualifying degree is a baccalaureate degree or higher in geology or a related geological science from a program accredited by the Applied and Natural Science Accreditation Commission of ABET Inc. Visit the ABET website to determine if you have an ABET accredited degree. List your ABET accredited degree(s) below. If you do not have an ABET accredited degree, describe your education under the qualifying coursework option.

NAME AND LOCATION OF INSTITUTION ATTENDAN CE (MM/YY) COURSE OF STUDY

DATE OF DEGREE TYPE OF DEGREE FROM TO

Qualifying Coursework Option for a PG license In accordance with Business and Professions Code section 7841(b)(2) and Title 16, California Code of Regulations Code section 3022(a)(2), qualifying coursework for a geology license includes completing 30 semester hours/45 quarter hours of coursework relevant to geology which must include at least 24 semester hours /36 quarter hours of upper division or graduate courses. The coursework must include the minimum required courses described in Title 16, California Code of Regulations section 3022(a)(2). List the relevant information below. Refer to the FAQs Regarding Geology and Geophysics Licensure Requirements on the Board’s website for additional information.

NAME AND LOCATION OF INSTITUTION ATTENDAN CE (MM/YY) COURSE OF STUDY

DATE OF DEGREE (IF ANY)

TYPE OF DEGREE FROM TO

REQUIRED CORE GEOLOGICAL SCIENCE COURSES IN ACCORDANCE WITH TITLE 16, CALIFORNIA CODE OF REGULATIONS SECTION 3022(a)(2)(A) REQUIREMENT NAME OF COMPLETED COURSES NUMBER OF

SEMESTER/QUARTER HOURS

UPPER/LOWER DIVISION OR

GRADUATE LEVEL Earth Materials (4 semester hours/6 quarter hours)

Structural Geology (3 semester hours/4.5 quarter hours)

Applicant’s Signature (Wet Signature Required) Date:

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Applicant’s Name (Last) (First) (Middle)

REQUIREMENT (CONTINUED) NAME OF COMPLETED COURSES NUMBER OF SEMESTER/QUARTER

HOURS

UPPER/LOWER DIVISION OR

GRADUATE LEVEL Stratigraphy and Sedimentation (3 semester hours/4.5 quarter hours)

Upper Division Field Geology (5 semester hours/7.5 quarter hours)

REQUIRED APPLIED UPPER DIVISION GEOLOGY COURSES IN ACCORDANCE WITH TITLE 16, CALIFORNIA CODE OF REGULATIONS SECTION 3022(a)(2)(B)

NAME OF COMPLETED COURSES (Must include at least two of the topics described in Title 16, California Code of Regulations section 3022(a)(2)(B) for a total of 6 semester hours/9 quarter hours)

NUMBER OF SEMESTER/QUARTER

HOURS

UPPER DIVISION OR

GRADUATE LEVEL

NAME OF COMPLETED COURSES NUMBER OF SEMESTER/QUARTER

HOURS

UPPER/LOWER DIVISION OR

GRADUATE LEVEL

LIST ANY ADDITIONAL COURSEWORK REQUIRED TO MEET THE TOTAL OF 30 SEMESTER HOURS/45 QUARTER HOURS OF COURSEWORK RELEVENT TO GEOLOGY, WHICH MUST INCLUDE 24 SEMESTER HOURS/36 QUARTER HOURS OF UPPER DIVISION OR GRADUATE LEVEL

COURSEWORK REQUIRED IN ACCORDANCE WITH BUSINESS AND PROFESSIONS CODE SECTION 7841(b)(2).

Section 2B (Education): Professional Geophysicist (PGP) applicants complete this section List all degrees or education that qualifies in accordance with Business and Professions Code sections 7841.1(b)(1) or 7841.1(b)(2). Refer to the FAQs Regarding Geology and Geophysics Licensure Requirements on the Board’s website for additional information.

NAME AND LOCATION OF INSTITUTION ATTENDANCE (MM/YY)

FROM TO COURSE OF

STUDY DATE OF

DEGREE (IF ANY) TYPE OF DEGREE

If needed, use the space below for explanatory remarks or additional information regarding Sections 2A or 2B.

Applicant’s Signature (Wet Signature Required) Date:

Application for Licensure as a PG or PGp (Revised 11/2019) Version 1.0 Page 3 of 5

MONTHS

MONTHS

Applicant’s Name (Last) (First) (Middle)

Section 3 Qualifying Experience

All applicants must complete this section. List the information corresponding to each Independent Evaluation of Scope, Character and Duration of Applicant’s Qualifying Geological or Geophysical Work Experience form submitted with this application. A minimum of three (3) references are required for PG and PGP applications, or as many more as needed to sufficiently document that the applicant meets the qualifying experience requirements in accordance with the statutes and regulations. Read the Frequently Asked Questions (FAQs) Regarding Geology and Geophysics Licensure Requirements for detailed information regarding how to document qualifying experience, the definitions of qualifying experience, reference requirements, the types of reference providers that are accepted, etc.

EVALUATION NUMBER

From MM/DD/YY To MM/DD/YY

Employer Name of Reference Reference’s

License No./State

Months of Qualifying Experience

City/State/Country of Employer Professional Relationship License Type

1 MONTHS

2 MONTHS

3 MONTHS

MONTHS

MONTHS

MONTHS

MONTHS

MONTHS

9. REMARKS: Use this space for explanatory remarks or additional information, including information relating to Section 5, on page 5, of thisapplication.

Applicant’s Signature (Wet Signature Required) Date:

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Applicant’s Name (Last) (First) (Middle)

Section 4 Military Service

Are you currently or have you previously served in the military? Yes No

Are you relocating to California as a result of your spouse’s/domestic partner’s active duty military orders?

Yes No

(If you answered “No” to the question above, please proceed to Section 5.)

Pursuant to Business and Professions Code Section 115.5, the Board shall expedite the licensure process for an applicant who is married to or in a domestic partnership or other legal union with an active duty member of the U.S. Armed Forces who is assigned to a duty station in California under official active duty military orders and who holds a current license in another state, district or territory of the U.S. in the profession for which he or she is seeking licensure. If you would like to be considered for the expedited review process, provide the following documentation:

1) A copy of the marriage certificate or certified declaration/registration of domestic partnership;

2) A copy of military orders establishing duty station in California; and

3) A copy of the current license held in another state, district, or territory of the U.S.

4) Write, “MILITARY SPOUSE” on bottom left corner of the envelope to be expedited.

Section 5 Background/Discipline

Pursuant to Title 16, Division 29 of the California Code of Regulations Section 3021.1, all applicants are required to furnish to the Department of Justice a full set of fingerprints for the purpose of conducting a criminal history record check and to undergo a state and federal level criminal offender record information search. For more information on fingerprinting, go to the FAQs on the Board's website.

Have you ever been convicted of or plead guilty or nolo contendere [“no contest”] to ANY offense in the United States or a foreign country? This includes every citation, infraction, misdemeanor, and/or felony that resulted in a conviction or a plea of guilty or nolo contendere. NOTE: Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code sections 11357(b), (c), (d), (e), or section 11360(b) two years or older should NOT be reported. Convictions that were later expunged from the records of the court or set aside pursuant to Sections 1203.4, 1203.4a, or 1203.41 of the California Penal Code or equivalent non-California law MUST be disclosed.

Yes No

Exclusive of juvenile court adjudications and criminal charges dismissed under Section 1000.3 of the California Penal Code or equivalent non-California laws, or convictions two years or older under California Health and Safety Code Sections 11357(b), (c), (d), (e), or Section 11360(b), have you had a conviction that was set aside or later expunged from the records of the court? Yes No

Is any criminal action pending against you, or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict? Yes No

Have you ever had a geologist or geophysicist related license denied, disciplined, suspended, surrendered, or revoked in

any state (other than for lack of minimum qualification or failure of examination)?

If YES, explain under “Remarks” in Section 3, on page 4, of this application. Yes No

If you answered “Yes” to any of the above questions, you must submit the appropriate certified court documentation and a statement of explanation for each criminal conviction on an additional sheet of paper.

NOTICE: Under the laws of the State of California, the State Board of Equalization and the Franchise Tax Board are allowed to share taxpayer information with the Board for Professional Engineers, Land Surveyors, and Geologists. The laws require a licensee to pay his or her state tax obligation, and his or her license may be suspended if the state tax obligation is not paid.

Applicant’s Signature (Wet Signature Required) Date:

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