2010-2011 APPLICATION FOR REGISTRATION RENEWAL

PLEASE COMPLETE AND RETURN PROMPTLY TO AVOID LATE PAYMENT PENALTIES

All checks must be payable to the Treasurer of Guam and mail directly to:

The Guam Board of Registration for PEALS
East-West Business Business Center
Unit D-Suite 208, 718 North Marine Drive
Upper Tumon, GU 96913

FEE: $225.00 per type of registration
(if engineering branch or discipline)
Due: On or before 04/30/2010
Add: $25.00 per month after 04/30/2010

I, declare under penalty perjury that the following declaration is true and correct: (PRINT NAME)

I am a Registered:

I am Employed or Associated with:

Email Address:

Preferred Mailing Address:

1. Has any disciplinary action ever taken against you since your last renewal? If YES, please explain (use the back of this form).	YES	NO
2. Are there any disciplinary actions pending against you? If YES, please explain on a separate sheet. ...	YES	NO
3. Have you read, understood, subscribe to the Rules of Professional Conduct for Professional Engineers, Architects and Land Surveyors, known as Code of Ethics, and pledge to perform your professional services in accordance with the aforementioned rules?	YES	NO
If NO, please explain:


Registrant's Signature	Date

DO NOT WRITE BELOW THIS LINE

Amount Paid: