REGISTRATION RENEWAL

PLEASE COMPLETE AND RETURN PROMPTLY TO AVOID LATE PAYMENT PENALTIES

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

The Guam Board of Registration for PEALS
East-West Business Center, Unit D-Suite 208
718 N. Marine Corps Drive
Tamuning, GU 96913

FEE:	$225.00 per type of registration (if engineering, per branch or discipline)
Due:	On or before 04/30/2011
Add:	$25.00 per month after 04/30/2011

I, declare under penalty of perjury that the following declaration

(PRINT NAME)

is true and correct.

I am a Registered		I am Employed or Associated with:
	Engineer # Discipline:	Business Name:
	Architect #	Business Address:
	Landscape Architect #
	Land Surveyor #	Business Telephone Number: ( ) -
Email Address:
Preferred MAILING Address:

1.	Has any disciplinary action ever been taken against you from the last 2 years? If YES, please explain using the back of this form.	Yes No
2.	Are there any disciplinary actions pending against you? If YES, please explain using the back of this form.	Yes No
3.	Have you read, understood and subscribe to the Rules of Professional Conduct for Professional Engineers, Architects, Land Surveyors and Landscape Architects, known as "Code of Ethics", and pledge to perform your professional services in accordance with the aforementioned rules? If NO, please explain using the back of this form.	Yes No

AMOUNT PAID:
PR Number: