STATE OF CALIFORNIA
GOVERNOR EDMUND G. BROWN JR.
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 CERTIFICATION AS AN ENGINEER-IN-TRAINING OR A LAND SURVEYOR-IN-TRAINING FEE: $50.00
Payable to Department of Consumer Affairs (DCA) by Check or money order only. Applications submitted without the appropriate fee will be returned.
FOR OFFICE USE ONLY
EMS ID No._____________________ ATS ID No. _____________________
CHECK ONE:
E.I.T.
L.S.I.T.
Type your name exactly as you want it to appear on your wall certificate. Please Note: The names and addresses of Board licensees and certificate holders 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, or a business address where you can receive mail.
Applications without a SSN or ITIN will not be processed, and will be returned to sender.
1. SOCIAL SECURITY NUMBER (SSN) or INDIVIDUAL TAXPAYER IDENTIFICATION
NUMBER (ITIN)
2. LAST 3. ADDRESS OF RECORD
FIRST CITY
MIDDLE STATE ZIP CODE
4. BIRTH DATE (MM/DD/YYYY) E-MAIL ADDRESS / / 5. DAYTIME PHONE NUMBER ALTERNATE PHONE NUMBER ( ) ( ) 6. MINIMUM E.I.T. QUALIFICATIONS (For E.I.T. applicants only)
YES A. Have you completed at least three years postsecondary (college level) engineering education or three years engineering work experience, or a combination of the two that total at least three years? B. Have you ever been convicted of a crime (including entering a plea of nolo contendere) other than for a minor traffic offense? If YES, you MUST explain AND submit certified court documents for each conviction with this application. Convictions dismissed under Penal Code 1203.4 must be disclosed. 7. MINIMUM L.S.I.T. QUALIFICATIONS (For L.S.I.T. applicants only) YES A. Have you completed at least two years of postsecondary (college level) education in land surveying or two years land surveying work experience, or a combination of the two that total at least two years? B. Have you ever been convicted of a crime (including entering a plea of nolo contendere) other than for a minor traffic offense? If YES, you MUST explain AND submit certified court documents for each conviction with this application. Convictions dismissed under Penal Code 1203.4 must be disclosed. 8. I have passed the NCESS Fundamentals of Engineering or Fundamentals of Surveying exam as specified below: NCEES ID# DATE LOCATION
NO
NO
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Handwritten Signature (Required) Date
*Use typewriter or complete online, print, sign, and mail this application. Handwritten forms are not accepted.
EIT/LSIT PAGE 1 OF 2
(rev 1/2014)
APPLICANTS NAME
(Last)
(First)
(M.I.)
List below the education and/or work experience that qualifies you for E.I.T./L.S.I.T. certification: EDUCATION QUALIFICATIONS (if applicable): Important: E.I.T. applicants in their last semester or quarter of their third year of an engineering education program are considered to be qualified. L.S.I.T. applicants in their last semester or quarter of their second year of a land surveying education program are considered to be qualified.
UNIVERSITY OR COLLEGE MAJOR FIELD OF STUDY UNITS COMPLETED
SEMESTER QUARTER
DIPLOMA, DEGREE OR CERTIFICATE OBTAINED
DATE COMPLETED
WORK EXPERIENCE QUALIFICATIONS (Attach additional pages if necessary)
FROM (MM/DD/YY) HOURS PER WEEK TO (MM/DD/YY) TOTAL WORKED (YEARS/MONTHS) TITLE/JOB CLASSIFICATION COMPANY/STATE AGENCY NAME SUPERVISOR NAME SUPERVISOR PHONE NUMBER
DUTIES PERFORMED (MUST include specific tasks and projects):
FROM (MM/DD/YY) HOURS PER WEEK
TO (MM/DD/YY) TOTAL WORKED (YEARS/MONTHS)
TITLE/JOB CLASSIFICATION COMPANY/STATE AGENCY NAME
SUPERVISOR NAME SUPERVISOR PHONE NUMBER
DUTIES PERFORMED (MUST include specific tasks and projects):
FROM (MM/DD/YY) HOURS PER WEEK
TO (MM/DD/YY) TOTAL WORKED (YEARS/MONTHS)
TITLE/JOB CLASSIFICATION COMPANY/STATE AGENCY NAME
SUPERVISOR NAME SUPERVISOR PHONE NUMBER
DUTIES PERFORMED (MUST include specific tasks and projects):
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.
EIT/LSIT PAGE 2 OF 2
(rev 1/2014)
