REQUEST FOR VERIFICATION OF LICENSURE OR EXAMINATION - (F5)
(If a fee is required, please notify the applicant but do not delay return of this form)
| FROM: | Guam Professional Engineers, Architects and Land Surveyors East-West Business Center, Unit D-Suite 208 718 N. Marine Corps Drive Tumon, GU 96913 |
Name: Address: |
File No.
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| TO: | SS#: DOB: |
/ / |
I. THE ABOVE NAMED PERSON WAS CERTIFIED OR LICENSED AS:
| Certificate# | Date Issued | Valid Until | ||
|---|---|---|---|---|
| ENGINEER-INTERN | / / | / / | ||
| PROFESSIONAL ENGINEER | / / | / / | ||
| STRUCTURAL ENGINEER | / / | / / | ||
| LAND SURVEYOR-INTERN | / / | / / | ||
| PROFESSIONAL LAND SURVEYOR | / / | / / | ||
| OTHER | / / | / / |
II. BASIS OF LICENSURE
| 1. | Written Examination |
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| California State Specific/ Other | ||||||||||||||||||||||||||||||||||||||||||
| 2. | Oral Examination | Hrs. PE Hrs. PLS | ||||||||||||||||||||||||||||||||||||||||
| 3. | FE/FLS ACCEPTED FROM: | |||||||||||||||||||||||||||||||||||||||||
| PE/PLS ACCEPTED FROM: | ||||||||||||||||||||||||||||||||||||||||||
| 4. | OTHER: | |||||||||||||||||||||||||||||||||||||||||
III. QUESTIONS:
| 1. | Has any disciplinary action ever been taken against the applicant? | Yes No |
| 2. | If yes, has this disciplinary case been satisfied to the Board’s requirements? | Yes No |
| 3. | Was the NCEES Cut-Score used? | Yes No |
| If no, please explain: | ||
IV. REMARKS:
| Completed by : | (SEAL) | |
| Title: |