The Ohio 4011 D form serves as the renewal application for dual Professional Engineer (P.E.) and Professional Surveyor (P.S.) licenses in Ohio. This form is essential for professionals seeking to maintain their licenses for the 2012-2013 period, ensuring compliance with state regulations. Completing this application accurately is crucial, as it verifies that all continuing education requirements have been met.
The Ohio 4011 D form is an essential document for individuals seeking to renew their Dual Professional Engineer (P.E.) and Professional Surveyor (P.S.) licenses in the state of Ohio. This form serves as a reminder of the renewal process, emphasizing the importance of completing continuing professional development requirements as outlined in Ohio law. Applicants must provide their names, addresses, and license numbers, along with a renewal fee of $80, which increases to $120 if submitted after the deadline. The form also includes sections for notifying the board of any name or address changes, as well as inquiries regarding any criminal convictions that may affect the renewal process. It is crucial for applicants to certify their compliance with the continuing education requirements, confirming they have completed the necessary professional development hours or are exempt due to recent registration. Importantly, this form is strictly for license renewals and cannot be used for reinstatement purposes. For those who prefer a quicker process, online renewal is encouraged, and additional resources are available on the board's website.
OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS BOARD USE ONLY
4011-D
2012-2013 Ohio Dual P.e., P.S. License
renewal Application
reMINDer! For faster license renewal, renew online at www.peps.ohio.gov.
DO NOt SUBMIt application if continuing professional development require- ments are not complete in accordance with section 4733.151 of the Ohio R.C.
NAMe AND ADDreSS reQUIreD
NAME
P.e. AND P.S. NUMBerS reQUIreD
PE–
PS–
ADDRESS
$80.00 DUe NOW
AMOUNT DUE After 12/31/2011: $120.00
CITY
STATE ZIP CODE
Make your check or money order payable in U.S.
funds to treasurer, State of Ohio.
►
NAMe cHANGe AND/Or cHANGe Of ADDreSS ONLy
NAME CHANGE reQUIreS LeGAL DOcUMeNtAtION
STATE
ZIP CODE
OHIO COUNTY reQUIreD If OHIO ADDreSS
I do not plan to renew at this time.
IMPOrtANt — DO NOt USe tHIS
fOrM fOr reINStAteMeNt!
this application cANNOt be used for reinstatement of a professional license. It is to be used for 2012-2013
P.E., P.S. renewals only. Email the Board, at pes.board@ pes.ohio.gov, for reinstatement instructions.
DO NOt SUBMIt copies of continuing professional development information with this application.
yeS NO I certify that I have completed 15 continuing professional development hours in accordance with section 4733.151
of the Ohio Revised Code –Or– I’m exempt from this requirement because I was granted initial registration during calendar year 2011.
If you answered NO to this question, DO NOt submit this renewal application.
FOR MORE INFORMATION REGARDING THE CPD REQUIREMENT, CPD AUDIT, AND DOWNLOADING CPD ACTIVITY LOGS, VISIT OUR WEBSITE AT www.peps.ohio.gov.
yeS NO Since your last renewal have you been convicted of or pleaded guilty to any felony or crime involving moral turpitude or had your registration revoked, voluntarily surrendered or suspended by another jurisdiction? If yeS, please give date, type of conviction, court of conviction, case number, and explanation.
ATTACH SEPARATE SHEET IF NEEDED
I certIfy that this is a properly completed and accurate license renewal application which I am submitting to the state of Ohio’s State Board of Registration for Professional Engineers and Surveyors. I have not omitted any requested information. I
understand that my renewal is contingent upon satisfactory completion of all requirements. I further understand that any person who knowingly makes false statements on the renewal application is guilty of falsiication under section 4733.20 of the Ohio
Revised Code, and subject to penalties under law.
Applicant Signature
2012-2013 DUAL Pe PS LIceNSe reNeWAL
STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS
50 W BROAD ST STE 1820 COLUMBUS OH 43215-5905
Date Signed
Make check or money order payable in U.S. funds to treasurer, State of Ohio. Cash is not accepted. for credit card payment, renew online. Send completed, signed, and dated application and fee; postmarked no later than 12/31/2011; to the Board address at left.
PES 4011-D (Rev. 10/2011) 1020
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