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Application Check ListCover SheetApplicant Name:Last four of SSN:IncludedRequired DocumentsApplicant NotesRequestedPlease check oneCurrent ApplicationCheck, Credit Card Authorization Form or Money OrderTranscriptsCredential Evaluation (only for foreign/NON ABET degrees)Verification of Fundamentals Exam & CertificationVerification of Professional Exam & LicensurePersonal ReferencesExperience Record FormsVerification of Experience FormsRequired Online Application QuizzesLaws & Rules Quiz (submitted online)Professionalism & Ethics Quiz (submitted online)Comments:completed ‐ achieved 90% orbetter
Louisiana Professional Engineering and Land Surveying BoardApplication for Licensure as a Professional Engineerby ComityApplying under the provisions of La. R.S. 37:693(B)(2)(b): ComityA 180 non-refundable fee is to be submitted with this application. Make checks or Money Order payable to LAPELS or you may usethe credit card authorization form.Do not complete this form until you have read and thoroughly understand this form and the accompanying instructions. Do not leaveany section blank and state “not applicable” or “none” if such is the case. All information must be typed. Hand written applicationsare not acceptable.Date of application:I am applying for comity from the following jurisdiction:I wish to be listed in the discipline of select oneMyNCEES #engineering1. PERSONAL INFORMATIONSSN:Name:Last NameFirst NameMiddle/Maiden e:Work Phone:US Citizen? YesNoselect countryE-Mail:City ofBirth:Date of Birth:Gender:Zip:State ofBirth:If no, what country?select countryCountry ofBirth:select countryVisa/Green Card #:2. EDUCATIONList in chronological order, the name and location of each college or university where a degree was conferred or is in progress, thetime spent at each institution, and if graduated, the date of graduation, the degree received and the major as shown on yourtranscript. See the instructions concerning submitting transcripts and if applicable, a credential evaluation. Transcripts must besubmitted by your college/university directly to LAPELSInstitution InformationTypeNameYears AttendedStateFrom - ToGraduationDateDegreeReceived andMajorTech SchoolTech SchoolTech School9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809-1433 (225) 925-6291 Fax (225) 925-6292 www.lapels.com/MODIFIED OCT 2018
3. PROFESSIONAL EXAMINATION AND LICENSURE/CERTIFICATION IN LOUISIANA AND OTHERJURISDICTIONSJurisdictionDateBasis of LicenseFirst PE LicenseNCEES ExamFundamentals (FE/EI) ExamNo. of hoursCertificate No.Principles and Practice (PE) ExamNo. of hoursLicense No.Do you have an active PE in any state? Mark one:YesOther: (explain):NoState(s):What state did you reside in one (1) year prior to taking the FE?If you made multiple attempts at this exam, list your number of attempts and jurisdictions:Number of AttemptsJurisdictionNumber of AttemptsJurisdictionNumber of AttemptsJurisdictionWhat state did you reside in one (1) year prior to taking the PE?If you made multiple attempts at this exam, list your number of attempts and jurisdictions:Number of AttemptsJurisdictionNumber of AttemptsJurisdictionNumber of AttemptsJurisdiction4. PERSONAL REFERENCES (5 references, 3 must be actively licensed Professional Engineers). See rule change1701.B, effective 12/2015)NameMailing AddressCityStateZip9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.com/MODIFIED OCT 2018
5. VIOLATIONSHave you ever been convicted of a felony or of a crime of moral turpitude or entered a plea of guilty or nolo contendere to a felonycharge or to a crime of moral turpitude under the laws of the United States or any state, territory or district of the United States?Mark one:YesNoHave you ever been convicted of any crime or entered a plea of guilty or nolo contendere to any criminal charge an element of whichis fraud or which arises out of your practice of engineering or land surveying?Mark one:YesNoHave you ever been convicted of any civil or criminal violation of, or entered a plea of guilty or nolo contendere to any criminalcharge under, the Louisiana Campaign Finance Disclosure Act or any other campaign finance and/or practices laws of the State ofMark one:YesNoLouisiana, the United States, or any state, territory or district of the United States?Have you been the subject of a disciplinary or enforcement action by the engineering or land surveying licensing authority in anyNoN/Astate, territory or district of the United States?Mark one:YesAre you an owner, partner, officer, director, managing member or supervising professional of a firm whose license, permit orcertificate to practice engineering or land surveying has ever been the subject of a disciplinary action by any state, territory or districtYesNoof the United States?Mark one:If the answer to any of these questions is “Yes”, provide the date and the pertinent facts of the case or proceeding including its finaldisposition. Attach additional pages as necessary.DISCLOSUREAs part of the application process, the Louisiana Professional Engineering and Land Surveying Board (LAPELS) will obtain a consumerreport, which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character,general reputation, personal characteristics, or mode of living.AUTHORIZATIONDuring the application process and at any time during the tenure of my licensure with LAPELS, I hereby authorize LexisNexisWorkPlace Solutions Inc., on behalf of LAPELS, to procure a consumer report which I understand may include information regardingmy credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. Thisreport may be compiled with information from credit bureaus, court record repositories, departments of motor vehicles, past orpresent employers and educational institutions, governmental occupational licensing or registration entities, business or personalreferences, and any other source required to verify information that I have voluntarily supplied. I understand that I may request acomplete and accurate disclosure of the nature and scope of the background verification and a written summary of consumer rights;to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or modeof living.Applicant SignatureDatePrint NameDate of Birth *Social Security Number ** For Identification Purposes Only9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.com/MODIFIED OCT 2018
***YOU MUST COMPLETE THIS SECTION. INITIAL THE FIRM OPTION BELOW WHICH WILL BEST DESCRIBE YOUREMPLOYMENT IN LOUISIANA***6. Please be advised that LA R. S. 37:689 requires firms practicing or offering to practice engineering or landsurveying in the state of Louisiana to be licensed by the Board prior to offering such services.If approved for licensure in Louisiana, I will be employed by:Initial below:This firm is currently licensed in Louisiana with EF #This firm is not licensed with Louisiana.I understand a firm application needs to be submitted within 3 weeks of receiving a Louisiana comity license.I am a Sole Proprietor. Refer to §Rule 2301.CFor your convenience, here is a link to the firm s/firm/firm application.pdfHere is the link to Chapter 23 from the LAPELS Rules that addresses firm licensure and supervising professional ns/firm/Chapter 23 Firms.pdfComments:Payment Type:For LAPELS office use only – do not write in this areaCheck #Credit Card Confirmation #Money Order #Payment Amt.ApplicationCAVUNCEESBackground7. ACKNOWLEDGMENTI, the applicant named in this application, have read the contents hereof, and to the best of my knowledge, information and belief thestatements and information in this application are true and correct in substance and effect and are made in good faith. I have notomitted any information requested in this application. I am aware that such an omission or untrue response may constitute fraud ordeceit, material misstatement, perjury or the giving of false or forged evidence under Louisiana Revised Statutes 37:698 and 37:700. Iunderstand and agree that any responses verifying my education, personal references, and experience shall be considered privilegedand confidential and that this information was not reviewed by me nor will it be available for my inspection or review in the future.I have read the Rules for Professional Engineers and Land Surveyors (LAC Title 46, Part LXI), and I agree to conduct my professionalaffairs in accordance with these rules.Signature of Applicant:9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809-1433 (225) 925-6291 Fax (225) 925-6292 www.lapels.com/MODIFIED OCT 2018
INSTRUCTIONS FOR COMPLETING EXPERIENCE RECORD FORMSALL TIME SINCE GRADUATION WITH BS DEGREE MUST BE DOCUMENTED ON AN EXPERIENCE RECORD FORM. You must includemilitary, illness, unemployment or time spent completing an additional college degree, etc., on an Experience Record form. Timegaps will result in an incomplete application. The chart below is an example of the 8 column Experience Record form. Theinstructions below indicate how to complete the information in each of the columns.1st column: Record number (start with first employment – end with current employment)2nd column: Start date & end date for this record. The ending date for your current employer should be the same month & year asthe application date. Dates must be reflected in “mm/yyyy” format. “Current” and/or “present” are not acceptable timeframes.3rd column:a. Position titleb. Company namec. Detailed description of experience (see paragraph below)*. Indicate character, magnitude & complexity of your work, yourduties & degree of responsibility. When describing experience, refer to Chapter 15, specifically Rules 1515, 1517 and 1519.Inadequate descriptions will delay the review process. Click here for additional information regarding the description of yourexperience.d. Name, title and present address of the supervisor or person most familiar with this engagement.4th through 8th columns: List amount of time for this experience record in years & months, in the appropriate category.*Applicant must comply with LAPELS Rule §1527 Supervision by Licensed Professional:A. Engineering. Experience should be gained under the supervision of a professional engineer holding a valid license to engage in thepractice of engineering issued to him/her by proper authority of a state, territory, or possession of the United States, or the District ofColumbia, or, if not, an explanation shall be made showing why the experience should be considered acceptable.(You may add an explanation to the Experience Record form or include a separate note.)EXPERIENCE RECORD EXAMPLE(4)(5)(6)(7)(8)Academic Engagementb. Company NameTimes of each employment category(years and months)Engineering experience subsequent to PElicensurea. Position titleEngineering experience subsequent to FEExam and prior to PE licensure01/199904/2013Engineering experience subsequent to BSdegree & prior to FE Examination1Doe, JohnNon‐engineering employmentName (Last, First):c. Description of experience(1)(2)(3)d. Supervisor name, title & current addressBegin listing your experience on the forms following this page, starting with your first employment. Use the TAB key to movebetween shaded fields. Click here for additional pages, if necessary. Remember, you must document all time subsequent to yourgraduation: military, illness, unemployment or time spent completing an additional college degree, etc. Once you have completedall of your experience, tally the time for each category in the box on the last page. These totals must be completed and correspondwith all time on your experience records.9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.com/MODIFIED OCT 2018
NAMEEXPERIENCE RECORDymymymAcademic EngagementNon‐engineering employmentc.Engineering experience subsequent to PE licensureb.Engineering experience subsequent to FE Examand prior to PE licensure‐Engineering experience subsequent to BS degree &prior to FE ExaminationTimes of each employment category(years and months)a.ymd.continued on next page9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.comMODIFIED OCT 2018ym
NAMEEXPERIENCE RECORDymymymAcademic EngagementNon‐engineering employmentc.Engineering experience subsequent to PE licensureb.Engineering experience subsequent to FE Examand prior to PE licensure‐Engineering experience subsequent to BS degree &prior to FE ExaminationTimes of each employment category(years and months)a.ymd.continued on next page9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.comMODIFIED OCT 2018ym
NAMEEXPERIENCE RECORDymymymAcademic EngagementNon‐engineering employmentc.Engineering experience subsequent to PE licensureb.Engineering experience subsequent to FE Examand prior to PE licensure‐Engineering experience subsequent to BS degree &prior to FE ExaminationTimes of each employment category(years and months)a.ymd.continued on next page9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.comMODIFIED OCT 2018ym
NAMEEXPERIENCE RECORDymymymAcademic EngagementNon‐engineering employmentc.Engineering experience subsequent to PE licensureb.Engineering experience subsequent to FE Examand prior to PE licensure‐Engineering experience subsequent to BS degree &prior to FE ExaminationTimes of each employment category(years and months)a.ymd.continued on next page9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.comMODIFIED OCT 2018ym
Once you have completed all of your experience, tally the time for each category in the box below.These totals must be completed and correspond with all time on your experience records.7. EXPERIENCE RECORD SUMMARYName (Last, First):GRAND TOTALS OF ALL EXPERIENCE: (Thesefields must be completed) (5)(6)(7)(8)Engineering experiencesubsequent to FE Exam and priorto PE licensureEngineering experiencesubsequent to PE licensureAcademic EngagementNon‐engineering employment(4)Engineering experiencesubsequent to BS degree & priorto FE ExaminationTimes of each employment category(years and months)yyyyymmmmm9643 Brookline Avenue Suite 121 Baton Rouge, Louisiana 70809‐1433 (225) 925‐6291 Fax (225) 925‐6292 www.lapels.comMODIFIED OCT 2018
Credit Card Authorization FormPLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO USAll information will remain confidential.Cardholder Name:Name on Application:(if different from credit card holder)Billing Address:City:State:Phone Number:Credit Card Type:Zip Code:Email:VisaMasterCardDiscoverAmerican ExpressCredit Card Number:Expiration Date:(MM/YY)Card Identification Number (3 digits on back of Visa/MC/Discover, 4 digits on front of AMEX):Amount to Charge (USD):Fee: Service Fee: Total: I authorize LAPELS to charge the agreed amount listed above to my credit card provided herein. Iagree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.Cardholder: Print Name and Date belowElectronic signature:(type your name)Date:Once signed, click the Submit button below to email to LAPELS Applications staff, or return by mailwith the completed application to the following address:LAPELSATTN: APPLICATIONS9643 BROOKLINE AVENUE, SUITE 121BATON ROUGE, LA 70809OFFICE USE ONLYApplication TypeConfirmation Number
Electronic Check Authorization Form(U.S. Banks only)PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO USAll information will remain confidential.Name on Account:Name on Application:(if different from account holder)This is a business accountThis payment is for a/an: select oneBilling Address:City:State:Zip Code:Country: select countryPhone Number:CheckingEmail:SavingsRouting Number:Account Number:Yes, I authorize this transaction. Please print this page if you would like a copy of this authorization foryour records. By checking “Yes” and opting to pay by electronic debit against the bank account specified above, Iagree and stipulate to all statements:1. I am the legal owner, have power of attorney, or have legal authority in relation to the bank account specified above tobe used for payment.2. Such bank account is open, validly issued, in good standing and able to accept electronic debits.3. Louisiana Interactive or its agent is authorized to electronically debit the bank account shown above, and if necessary, tocredit such account to correct any erroneous debits using an Automated Clearing House (“ACH”) debit entry.4. This ACH debit authorization will remain in full force and effect for this single debit entry only.5. Louisiana Interactive or its agent may re-debit my account for the payment in the event such is dishonored by myfinancial institution, and is additionally authorized to charge the maximum return item processing fee according tothe laws governing Louisiana Interactive's state.6. For inquiries relating to this electronic debit authorization, including revocation of this authorization, I may contactLouisiana Interactive at 225-325-5450.7. I understand the Originating ID for this transaction is “1522077581”. Please make sure your banking institution hasreleased any debit blocks (if applicable) for this ID to ensure successful payment.I (we) agree that ACH transactions I (we) authorized comply with all applicable NACHA Rules and all applicable US law andthe laws governing Louisiana Interactive's state.Amount to Charge (USD):Fee: Service Fee: Total: Electronic signature:(type your name)Date:Once signed, click the Submit button below to email to LAPELS Applications staff, or return by mail withthe completed application to the following address:LAPELSATTN: APPLICATIONS9643 BROOKLINE AVENUE, SUITE 121BATON ROUGE, LA 70809OFFICE USE ONLYApplication TypeConfirmation Number
3. PROFESSIONAL EXAMINATION AND LICENSURE/CERTIFICATION IN LOUISIANA AND OTHER JURISDICTIONS Jurisdiction Date Basis of License First PE License NCEES Exam Other: (explain): Fundamentals (FE/EI) Exam No. of hours Certificate No. Principles and Practice (
