East-West Business Center
Unit D-Suite 208 718 N. Marine Corps Drive
Upper Tumon, GU 96913
Tel: 671/646-3113; 646-3115, Fax: 671-649-9533
Website: www.guam-peals.org
Email: info@guam-peals.org
New
Amendment
Renewal
FOR BOARD'S USE ONLY
CERTIFICATE OF AUTHORIZATION APPLICATION
1
FIRM NAME/BUSINESS ADDRESS:
2
TYPE OF OWNERSHIP:
Corporation
Sole Proprietorship
Partnership
Other:
Limited Liability Company
1a
APPLICATION IS FOR:
Parent Company
Branch or Subsidiary (complete block 3)
2a
PRESENT FIRM INCORPORATED OR ORGANIZED IN:
CITY
STATE
DATE
3
NAME OF PARENT COMPANY/Business Address, if any:
4
PROFESSIONAL SERVICES to be provided:
Engineering
Branch or Discipline:
Architecture
Landscape Architecture
Land Surveying
Construction Management
5
RESPONSIBLE MANAGING EMPLOYEE (RME) FOR PROFESSIONAL SERVICES TO BE PROVIDED.
NAME
PROFESSIONAL SERVICE
GUAM REG NO.
SIGNATURE
6
GUAM OFFICE, IF DIFFERENT FROM BLOCK 1 (Provide map and/or direction to business office).
BUSINESS (Physical Address):
TEL #.:
FAX:
EMAIL:
MAILING ADDRESS (only if different from business address):
7
RESPONSIBLE MANAGING EMPLOYEE IN FULL CONTROL OF GUAM OPERATIONS.
NAME
RESIDENCE ADDRESS (Not a P.O. Box)
LICENSE/
REG NO
SIGNATURE
8
NAMES AND TITLES OF OFFICERS OR CORPORATE DIRECTORS (if a corporation), OR NAMES OF PARTNERS (if partnership), or MEMBERS OF THE ENTITY (if association). USE ADDITIONAL SHEETS IF NEEDED PROVIDED IT IS ON THE SAME FORMAT.
NAME:
POSITION TITLE:
SIGNATURE:
RESIDENCE ADDRESS
LICENSE/REG NO
DISCIPLINE
STATE
STREET NO.
CITY/STATE
ZIP CODE
CONTACT INFO
EMAIL
NAME:
POSITION TITLE:
SIGNATURE:
RESIDENCE ADDRESS
LICENSE/REG NO
DISCIPLINE
STATE
STREET NO.
CITY/STATE
ZIP CODE
CONTACT INFO
EMAIL
NAME:
POSITION TITLE:
SIGNATURE:
RESIDENCE ADDRESS
LICENSE/REG NO
DISCIPLINE
STATE
STREET NO.
CITY/STATE
ZIP CODE
CONTACT INFO
EMAIL
9
GENERAL INFORMATION QUESTIONS: Has the entity (corporation, partnership, association, etc.) or any of the personnel designated in responsible charge above, or any principals of the entity been convicted of fraud, gross negligence, incompetence, or misconduct in the practice of engineering, architecture, landscape architecture or land surveying, or of a U.S. or state statute excluding minor traffic violations? If YES, please attach explanation.
YES NO
THIS FORM MUST BE SIGNED BY THE INDIVIDUAL LISTED IN BLOCK 7: I certify that the information furnished are true and correct to the best of my knowledge and belief. I further certify that I have read, understand and agree to comply with the provisions of Guam Revised Statutes, P.L. 30-35.
