application to retain surveyor-in-training certificate - Texas Board of ...
application to retain surveyor-in-training certificate - Texas Board of ...
application to retain surveyor-in-training certificate - Texas Board of ...
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TEXAS BOARD OF PROFESSIONAL<br />
LAND SURVEYING<br />
12100 Park 35 Circle, Build<strong>in</strong>g A, Suite 156 MC-230<br />
Aust<strong>in</strong> TX 78753<br />
Web: www.txls.state.tx.us<br />
Phone: 512 239 5263 Fax: 512 239 5253<br />
Office Use Only<br />
Transaction #<br />
Entity #<br />
Receipt #<br />
APPLICATION TO RETAIN SURVEYOR-IN-TRAINING CERTIFICATE<br />
Instructions for Fil<strong>in</strong>g Application<br />
A. Read all <strong>Board</strong> Rules before complet<strong>in</strong>g the <strong>application</strong>. Note that <strong>Board</strong> Rule 661.51 has specific <strong>in</strong>formation<br />
regard<strong>in</strong>g <strong>reta<strong>in</strong></strong><strong>in</strong>g the SIT Certificate.<br />
B. All <strong>in</strong>formation requested on this form must be clearly typewritten or lettered <strong>in</strong> black <strong>in</strong>k. All questions must be<br />
answered. Failure <strong>to</strong> complete any portion <strong>of</strong> the <strong>application</strong> form will result <strong>in</strong> the <strong>application</strong> be<strong>in</strong>g returned <strong>to</strong><br />
the applicant.<br />
C. The <strong>application</strong> should be prepared <strong>in</strong> duplicate. The orig<strong>in</strong>al must be returned <strong>to</strong> the <strong>of</strong>fice <strong>of</strong> the <strong>Board</strong>, and the<br />
applicant should <strong>reta<strong>in</strong></strong> the duplicate.<br />
D. An <strong>application</strong> fee <strong>of</strong> twenty-five dollars and 94 cents ($25.94) must accompany the <strong>application</strong>, which is<br />
non-refundable.<br />
E. Payment must be by money order, cashier’s check or certified check, made payable <strong>to</strong> the “<strong>Texas</strong> <strong>Board</strong> <strong>of</strong><br />
Pr<strong>of</strong>essional Land Survey<strong>in</strong>g”. Cash and personal checks will not be accepted.<br />
1. General Information<br />
Name <strong>in</strong> Full ________________________________________________________ Date_______________<br />
Social Security No.______________________ Driver’s License No._____________________<br />
Address (Indicate preferred mail<strong>in</strong>g address<br />
Residence Street ___________________________________________________________<br />
City ________________________________ State _________ Zip____________________<br />
Bus<strong>in</strong>ess Firm Name________________________________________________________<br />
Firm Number _____________________________<br />
Street or P. O. Box _________________________________________________________<br />
City ________________________________ State ____________ Zip_________________<br />
E-mail address ________________________________________________________________<br />
Telephone Numbers (<strong>in</strong>clude area code)<br />
Residence ( ) Bus<strong>in</strong>ess (____)________________________<br />
Date <strong>of</strong> Birth____________________ Place <strong>of</strong> Birth __________________________________<br />
Resident <strong>of</strong> <strong>Texas</strong> Yes No If No, where? ____________________________________________________<br />
Are you a US Citizen Yes No If No, give INS Status ___________________Card No. ________________<br />
2. Registration Other Than Under This Act<br />
Attach unmounted,<br />
recent, passport type<br />
pho<strong>to</strong>graph <strong>in</strong> this<br />
space. Trim<br />
pho<strong>to</strong>graph <strong>to</strong> fill the<br />
space.<br />
Use ballpo<strong>in</strong>t pen <strong>to</strong><br />
sign and date<br />
pho<strong>to</strong>graph.<br />
Are you Registered as a Surveyor <strong>in</strong> Other States? Yes No If Yes, complete the <strong>in</strong>formation below:<br />
State ___ By exam ___ Hours <strong>of</strong> Exam ____ Registration No ______ Date Registered ______ Expiration _____<br />
State ___ By exam ___ Hours <strong>of</strong> Exam ____ Registration No ______ Date Registered ______ Expiration _____<br />
Are you Registered/Licensed <strong>in</strong> any other pr<strong>of</strong>ession? Yes No If Yes, complete the <strong>in</strong>formation below:<br />
Pr<strong>of</strong>ession____________ State ___ Registration No ________ Date Registered _________Expiration ________<br />
Has any Registration/License been revoked or received discipl<strong>in</strong>ary action? Yes No ________________<br />
If Yes, give details (you may attach additional sheets) _______________________________________________
<strong>Board</strong> Rule 661.51 requires written pro<strong>of</strong> <strong>of</strong> completion <strong>of</strong> at least 32 hours <strong>of</strong> acceptable cont<strong>in</strong>u<strong>in</strong>g education that<br />
was completed s<strong>in</strong>ce first becom<strong>in</strong>g a SIT. Acceptable cont<strong>in</strong>u<strong>in</strong>g education for the 8 year period will be def<strong>in</strong>ed as<br />
follows:<br />
Successful completion <strong>of</strong> courses <strong>in</strong> areas support<strong>in</strong>g development <strong>of</strong> skill and competence <strong>in</strong> pr<strong>of</strong>essional land<br />
survey<strong>in</strong>g; participat<strong>in</strong>g <strong>in</strong> programs, sem<strong>in</strong>ars, workshops or conferences which provide <strong>in</strong>creased pr<strong>of</strong>essional<br />
knowledge related <strong>to</strong> the practice <strong>of</strong> pr<strong>of</strong>essional land survey<strong>in</strong>g and other cont<strong>in</strong>u<strong>in</strong>g education activities which<br />
are approved by the <strong>Board</strong>. <strong>Board</strong> approved cont<strong>in</strong>u<strong>in</strong>g education courses can be found on the <strong>Board</strong>'s web site,<br />
www.txls.state.tx.us .<br />
Date Completed<br />
Name <strong>of</strong> Course or Description <strong>of</strong> Activity<br />
(Indicate which courses are <strong>Board</strong> Approved)<br />
Hours<br />
Total Hours (must be at least 32)<br />
6. Certification<br />
I hereby certify under penalty <strong>of</strong> perjury that the <strong>in</strong>formation conta<strong>in</strong>ed here<strong>in</strong> is true and correct <strong>to</strong> the best <strong>of</strong> my knowledge,<br />
<strong>in</strong>formation and belief.<br />
_______________________________________________________<br />
Signature<br />
Date<br />
_______________________________________________________<br />
Pr<strong>in</strong>ted Name