The Ohio 3011 form is an application for a Certificate of Authorization, essential for firms wishing to offer professional engineering or surveying services in Ohio. This form facilitates new applications, annual renewals, and changes to services or firm names. Completing it accurately is crucial, as any omissions or errors may lead to processing delays or rejection.
The Ohio 3011 form serves as a critical component for firms seeking a Certificate of Authorization to provide professional engineering and surveying services in Ohio. This application is essential for both new firms and those looking to renew or modify their existing authorization. Key requirements include a notarized application, a notarized Firm Affidavit of Responsibility for each designated professional engineer or surveyor, and an active registration number from the Ohio Secretary of State. Additionally, firms must submit the appropriate application fee, which varies depending on the type of application—$50 for new services or name changes, $25 for annual renewals, and $37.50 for late renewals. The form mandates that all fields be completed unless specified otherwise, and incomplete applications will be returned. It is also important to note that Certificates of Authorization expire annually on June 30, and firms must notify the Board of any changes in ownership or firm details within 30 days. This application process ensures that firms maintain compliance with state regulations, thereby safeguarding the integrity of professional engineering and surveying practices in Ohio.
OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS
Certiicate of Authorization application instructions
3010
Each application must include…
•Notarized Certiicate of Authorization application: PES 3011 (Rev. 03/2011).
•Separate notarized Firm afidavit of responsibility for each professional engineer and professional surveyor designated in responsible charge: PES 3012 (Rev. 03/2011).
•An active Ohio Secretary of State charter or registration number authorizing the irm to do business in the state of Ohio. In addition, if a irm is using a doing business as (DBA) name, an active Ohio Secretary of State charter or registration number authorizing the irm’s DBA name to do business in the state of Ohio is needed.
•Appropriate application fee, using check or money order, and made payable in U.S. funds to treasurer, State of Ohio. NEW, ADDITIONAL SERVICE, or NAME CHANGE application fee is $50.00. ANNUAL RENEWAL application fee is $25.00. LATE ANNUAL RENEWAL application fee is $37.50.
Contacting Ohio’s Secretary of State
Contact information for the Ohio Secretary of State’s ofice is provided as a courtesy and may be subject to change.
•On the web www.sos.state.oh.us
•Telephone (877) 767-6446 U.S. toll free or (614) 466-2655 Columbus metro
important checklist information
•Application must be illed out completely. All ields are required unless otherwide indicated.
•Each full-time employee designated in responsible for, and responsible charge of, the professional engineering or pro- fessional surveying activities and decisions must ill out Firm afidavit of responsibility PES 3012 (Rev. 03/2011).
•The full-time employee must be a partner, manager, member, oficer or director and shall be registered in this state. Full- time, as deined in Ohio R.C. section 4733.16, means working more than 30 hours per week or working substantially all the engineering and/or surveying hours for a irm that holds a Certiicate of Authorization.
•The irm and/or its DBA must hold an active registration(s) with the Ohio Secretary of State.
•Applications without the correct fee or with incomplete information will be returned.
•All Certiicates of Authorization expire annually on June 30.
•Failure to renew the Certiicate of Authorization by the June 30 deadline renders the irm inactive and unauthorized to practice in the state of Ohio.
•Firms must notify the Board within 30 days of any change of the irm’s name or address.
•Firms are responsible for notifying the Board within 30 days of any changes of partners, managers, oficers, members, directors, shareholders, designated professional engineers, designated professional surveyors or change of ownership.
•Firms with a name change must ile a new application and include an application fee of $50.00.
•Firms adding an additional service must ile a new application and include an application fee of $50.00.
•Firms that do not wish to renew their Certiicate of Authorization must notify the Board in writing.
•A Certiicate of Authorization is not the same as an individual license to practice professional engineering or professional surveying in the state of Ohio.
Disclosure statement, privacy notice
Ohio’s State Board of Registration for Professional Engineers and Surveyors is requesting disclosure of information that is necessary to accomplish our statutory purposes required by Ohio Revised Code Chapter 4733. Failure to provide required information may result in your approval being delayed or your application being returned. Subject to certain Ohio Revised Code statutory exceptions, most documents and records maintained by the state of Ohio, including those maintained by the Board, are public records under Ohio law. This means that information submitted to us from you may be subject to disclosure if there is an oficial public records request.
Deliver completed Certiicate of Authorization application with afidavit(s) and fee to:
CERTIFICATE OF AUTHORIZATION
OHIO ENGINEERS AND SURVEYORS BOARD 50 W BROAD ST STE 1820
COLUMBUS OH 43215-5905
Questions?
EMAiL
pes.board@pes.ohio.gov
FAX
(614) 728-3059
U.S. tOLL FrEE
(877) 644-6364
PES 3010 (Rev. 03/2011) 20110301
Page 1 of 1
Certiicate of Authorization application
3011
This application is for irms requiring a Certiicate of Authorization in order to provide, or offer to provide, professional engineering and/or professional surveying services in Ohio. Use this application for new, annual renewal and late annual renewal approvals; or for adding an additional service or a name change. All ields required unless otherwise indicated. The appropriate nonrefundable application fee must be included using check or money order and made payable in U.S. funds to treasurer, State of Ohio. An incomplete application — or an application without the appropriate fee — cannot be processed and will be returned.
Application for >> CHOOSE ONLY ONE
$50.00 NEW
$25.00 ANNUAL rENEWAL
$50.00 ADDitiONAL SErviCE
$37.50 LAtE ANNUAL rENEWAL
$50.00 NAME CHANGE
ENTER PREVIOUS FIRM NAME >>
Ohio Certiicate of Authorization number >> rEQUirED unless new irm
Professional services to be offered by irm
Engineering ONLY
Surveying ONLY
Engineering AND Surveying
Firm is registered with the Ohio Secretary of State as
Corporation
LLC
Partnership
Professional Association
Other DESCRIBE FIRM TYPE >>
Firm contact information >> ALL FiELDS rEQUirED UNLESS OTHERWISE INDICATED
An active Ohio Secretary of State (SOS) charter or registration number authorizing the irm to do business in the state of Ohio is required for each irm name and irm DBA name, if used. Contact the Secretary of State at www.sos.state.oh.us.
OHIO SOS NO.
FIRM NAME
OHIO SOS NO. >> rEQUirED with DBA FIRM DBA >> ONLY if using DBA (Doing Business As) name
CONTACT EMAIL ADDRESS
FEDERAL EMPLOYER ID NUMBER
LOCAtiON OFFEriNG OHiO PrOFESSiONAL SErviCES
ADDRESS LINE 1 >> DO NOt USE AGENt ADDrESS — PO Box is NOt acceptable
Indicate if change of address
TELEPHONE
ADDRESS LINE 2 >> ONLY if needed
CITY
COUNTY >> ONLY if Ohio address
STATE ZIP+4
MAiLiNG ADDrESS >> ONLY IF DIFFERENT THAN ABOVE LOCATION
ADDRESS LINE 1
>> DO NOt USE AGENt ADDrESS
ADDRESS LINE 2
>> ONLY if needed
PES 3011 (Rev. 03/2011)
Page 1 of 4
Ownership If irm has more than four owners, attach additional pages with the same information.
1 FIRM OWNER NAME
FIRM OWNER ADDRESS
2 FIRM OWNER NAME
3 FIRM OWNER NAME
4 FIRM OWNER NAME
registered individuals in responsible charge All professional services shall be executed by, or be under the direct supervision of, an Ohio-registered professional engineer or professional surveyor. Pursuant to Ohio R.C. section 4733.16, each corporation, limited liability company, partnership or professional association through which professional engineering or surveying services are offered or provided in Ohio, shall designate one or more directors, partners, managers, members or oficers employed by the irm full time as being responsible for and in responsible charge of the professional engineering or professional surveying activities and decisions of the irm.
Name, registration number, position of registrant in responsible charge iMPOrtANt! Each registrant
listed as in responsible charge must include an accompanying Firm Afidavit of responsibility (PES 3012). If more than four registrants are in responsible charge, attach additional pages with the same information.
1 PRINTED NAME >> include notarized PES 3012iNDiCAtE ALL tHAt APPLY
Director
Partner
Manager
Member
Oficer
OHIO P.E. NUMBER
OHIO P.S. NUMBER
2 PRINTED NAME >> include notarized PES 3012
iNDiCAtE ALL tHAt APPLY
3 PRINTED NAME >> include notarized PES 3012
4 PRINTED NAME >> include notarized PES 3012
Page 2 of 4
Additional Ohio P.E., P.S. registrants employed by irm
List registrant name, registration number and irm location address of each Ohio P.E. or Ohio P.S. whose services are employed by the irm as of the date of this application. If needed, attach additional pages with the same information required below.
1 REGISTRANT NAME
FIRM LOCATION ADDRESS
2 REGISTRANT NAME
3 REGISTRANT NAME
4 REGISTRANT NAME
5 REGISTRANT NAME
6 REGISTRANT NAME
7 REGISTRANT NAME
Ohio’s State Board of Registration for Professional Engineers and Surveyors is requesting disclosure of information that is necessary to accomplish our statutory purpose required by Ohio R.C. Chapter 4733. Failure to provide required information may result in your application approval being delayed or your application being returned.
Subject to certain Ohio Revised Code statutory exceptions, most documents and records maintained by the state of Ohio, including those maintained by the Board, are public records under Ohio law. This means that information submitted to us from you may be subject to disclosure if there is an oficial public records request.
Page 3 of 4
Notarized afidavit
STATE OF
AFFiANt
I,[ PRINTED NAME ] ,
being duly sworn, or afirmed, depose and say that I am duly authorized to prepare this application for a Certiicate of Authorization and attest, to the best of my knowledge and belief, that the information contained herein is true.
DECLArAtiON in accordance with section 2909.32 (A)(2)(b) of the Ohio revised Code
For each question, indicate either “yes” or “no” in the space provided. Responses must be truthful to the best of your knowledge.
YES
NO
1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List?
2.
Have you used any position of prominence you have with any country to persuade others to support an organization
on the U.S. Department of State Terrorist Exclusion List?
3.
Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State
Terrorist Exclusion List?
4.
Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist
Exclusion List?
5.Have you committed an act that you know, or reasonably should have known, affords “material support or resources” to an organization on the U.S. Department of State Terrorist Exclusion List? .......................................
6.Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department of State Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an act of terrorism?....................................................................................................................................................
YES NO
AFFIANT SIGNATURE
AFFIANT TITLE
DATE SIGNED
NOtArY
Subscribed and sworn, or afirmed, to me this
day of
,
.
Witness my hand and seal hereon.
NOTARY SIGNATURE
MY COMMISSION EXPIRES
L
A
S
E
Y
R
T
ON
N
O
Page 4 of 4
Firm afidavit of responsibility
3012
Complete a separate Firm afidavit of responsibility for each professional engineer or professional surveyor who is designated in responsible charge. Afidavits of responsibility must accompany all Certiicate of Authorization applications.
Firm name, Ohio Board Certiicate of Authorization number
FIRM NAME >> SAME NAME as on Certiicate of Authorization application OHIO BOARD CERTIFICATE OF AUTHORIZATION NUMBER >> 5-DiGitS
Ohio registrant designated in responsible charge
OHIO P.E., P.S. OR DUAL (P.E. AND P.S.) REGISTRANT DESIGNATED IN RESPONSIBLE CHARGE
P.E. NUMBER
P.S. NUMBER
I,[ AFFIANT PRINTED NAME ] ,
being the duly sworn, or afirmed, afiant; state that I am a registered professional engineer and/or a registered professional surveyor in the state of Ohio as indicated above; that I am a full time employee of the above-named irm; that I am in responsible charge for and in responsible charge of the professional engineering or professional surveying activities and decisions of this irm; and that I meet the requirements pursuant to Ohio Revised Code Chapter 4733 for such designation.
PES 3012 (Rev. 03/2011) 20110301
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