The Ohio PES 3011 form is the application for a Certificate of Authorization, which allows companies to provide professional engineering and surveying services in Ohio. This form is essential for new applications, annual renewals, and any changes to the company's services or name. Completing the PES 3011 accurately and submitting it with the required fees is crucial for maintaining compliance with state regulations.
The Ohio PES 3011 form is a critical document for companies seeking to provide professional engineering and surveying services within the state. This form serves as the application for a Certificate of Authorization, which is mandatory for any entity wishing to operate in these professions. Each application must be accompanied by a notarized PES 3011 form and a separate notarized Company Affidavit of Responsibility (PES 3012) for each professional engineer or surveyor designated in responsible charge. Additionally, companies must possess an active registration number from the Ohio Secretary of State, which confirms their authorization to conduct business in Ohio. The form also requires the payment of a nonrefundable application fee, varying based on the type of application—whether it’s for a new authorization, annual renewal, late renewal, or a name change. It is crucial for applicants to ensure that all fields are completed accurately, as incomplete submissions will be returned. Furthermore, companies must be aware that their Certificate of Authorization expires annually on June 30, and failure to renew by this deadline results in the company becoming inactive. Companies are also required to notify the Board of any significant changes, including changes in ownership or company structure, within 30 days. Understanding these requirements is essential for compliance and to maintain the ability to practice professionally in Ohio.
OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS
3010
Certiicate of Authorization application instructions
Each application must include…
•Notarized Certiicate of Authorization application: PES 3011.
•Separate notarized Company afidavit of responsibility for each professional engineer and professional surveyor
designated in responsible charge: PES 3012.
•An active Ohio Secretary of State charter or registration number authorizing the company to do business in the state of Ohio. In addition, if a company is using a doing business as (DBA) name, an active Ohio Secretary of State charter or registration number authorizing the company’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, NAME CHANGE, or ADDING DBA 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 otherwise indicated.
•Each full-time employee designated in responsible for, and responsible charge of, the professional engineering or professional surveying activities and decisions must ill out Company afidavit of responsibility PES 3012.
•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 company that holds a Certiicate of Authorization.
•The company 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 company inactive and unauthorized
to practice in the state of Ohio.
•Companies must notify the Board within 30 days of any change of the company’s name or address.
•Companies 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.
•Companies with a name change must ile a new application and include an application fee of $50.00.
•Companies adding an additional service must ile a new application and include an application fee of $50.00.
•Companies 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 your completed Certiicate of Authorization application with afidavit(s) and fee to the Board’s address below.
CErTifiCATE Of AUTHOrizATiON
STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS 50 W BROAD ST STE 1820
COLUMBUS OH 43215-5905
Questions?
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pes.board@pes.ohio.gov
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(614) 728-3059
U.S. TOll frEE
(877) 644-6364
PES 3010 (Rev. 03/2012) 20120307 Page 1 of 1
OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS BOARD USE ONLY
3011
Certiicate of Authorization application
This application is for companies 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.
Application for >> CHOOSE ONLY ONE
$25.00 ANNUAl rENEWAl
$50.00 NEW
$50.00 AddiTiONAl SErviCE
$37.50 lATE ANNUAl rENEWAl
$50.00 NAME CHANgE or AddiNg dBA (doing Business As)
ENTER PREVIOUS COMPANY NAME >>
Ohio Certiicate of Authorization number >> rEQUirEd unless new company professional services to be offered by company
Engineering ONlY
Surveying ONlY
Engineering AND Surveying
Company is registered with the Ohio Secretary of State as
Corporation
LLC
Partnership
Professional Association
Other DESCRIBE COMPANY TYPE >>
Company contact information >> All fiEldS rEQUirEd UNLESS OTHERWISE INDICATED
An active Ohio Secretary of State (SOS) charter or registration number authorizing the company to do business in the state of Ohio is required for each company name and company DBA name, if used.
OHIO SOS NO.
COMPANY NAME
OHIO SOS NO. >> rEQUirEd with dBA COMPANY DBA >> ONlY if using dBA (doing Business As) name
CONTACT EMAIL ADDRESS
FEDERAL EMPLOYER ID NUMBER
lOCATiON OffEriNg OHiO prOfESSiONAl SErviCES
Indicate if change of address
ADDRESS LINE 1 >> dO NOT USE AgENT AddrESS — pO Box is NOT acceptable
TELEPHONE
ADDRESS LINE 2 >> ONlY if needed
COUNTY >> ONlY if Ohio address
CITY
STATE ZIP+4
MAiliNg AddrESS >> ONLY IF DIFFERENT THAN ABOVE LOCATION
ADDRESS LINE 1 >> dO NOT USE AgENT AddrESS
PES 3011 (Rev. 03/2012) 20120307
Page 1 of 4
Ownership If company has more than ive owners, attach additional pages with the same information.
1 COMPANY OWNER NAME
COMPANY OWNER ADDRESS
2 COMPANY OWNER NAME
3 COMPANY OWNER NAME
4 COMPANY OWNER NAME
5 COMPANY 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 company full time as being responsible for and in responsible charge of the professional engineering or professional surveying activities and decisions of the company.
Name, registration number, position of registrant in responsible charge
iMpOrTANT! Each registrant listed as in responsible charge must include an accompanying Company Afidavit of respon- sibility (PES 3012). If more than four registrants are in responsible charge, attach additional pages with the same information.
1 PRINTED NAME >> include notarized pES 3012
iNdiCATE All THAT ApplY
Director
Member
OHIO P.E. NUMBER OHIO P.S. NUMBER
Partner
Manager
Oficer
2 PRINTED NAME >> include notarized pES 3012
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 company
List registrant name, registration number and company location address of each Ohio P.E. or Ohio P.S. whose services are employed by the company as of the date of this application. If needed, attach additional pages with the same information required.
1 REGISTRANT NAME
COMPANY LOCATION ADDRESS
OHIO P.E. NUMBER
OHIO P.S. NUMBER
2 REGISTRANT NAME
3 REGISTRANT NAME
4 REGISTRANT NAME
5 REGISTRANT NAME
6 REGISTRANT NAME
7 REGISTRANT NAME
8 REGISTRANT NAME
9 REGISTRANT NAME
Page 3 of 4
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 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.
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.
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?....................................................................................................................................................
AFFIANT SIGNATURE
AFFIANT TITLE
DATE SIGNED
YES NO
NOTArY
Subscribed and sworn, or afirmed, to me this
day of
,
.
Witness my hand and seal hereon.
NOTARY SIGNATURE
MY COMMISSION EXPIRES
L N
E
A
O
S
T
Y
R
N
L
EMAIL
PES 3011 (Rev. 03/2012) 20120307 Page 4 of 4
Company afidavit of responsibility
Complete a separate Company 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.
Company name, Ohio Board Certiicate of
Authorization number
BOARD USE ONLY
3012
COMPANY NAME >> SAME NAME as on Certiicate of Authorization application
OHIO CERTIFICATE OF AUTHORIZATION NUMBER >> 5-DIGItS
Professional services to be offered by company
Engineering ONLY
Surveying ONLY
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
AffIANt
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 company; that I am in responsible charge for and in responsible charge of the professional engineering or professional surveying activities and decisions of this company; and that I meet the requirements pursuant to Ohio Revised Code Chapter 4733 for such designation.
AFFIANT SIGNATUREDATE SIGNED
NOtArY
ON
Deliver your completed Company afidavit of responsibility to the Board’s address below.
cErtIfIcAtE Of AUthOrIzAtION
STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS
50 W BROAD ST STE 1820 COLUMBUS OH 43215-5905
U.S. tOLL frEE
PES 3012 (Rev. 03/2012) 20120307 Page 1 of 1
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