Application to Renew Environmental Professional's License



STATE BOARD OF EXAMINERS OF ENVIRONMENTAL PROFESSIONALS

APPLICATION TO RENEW

ENVIRONMENTAL PROFESSIONAL'S LICENSE

DEEP use

(date stamp)

Pursuant to section 22a-133v-4(d)(2)(A) of the Regulations of Connecticut State Agencies, this application, a completed Continuing Education Credit Summary Form with attached certificates and $425.00 renewal fee must be received by the DEEP on behalf of the Board, at least 30 days prior to the expiration of your license. Since all licenses expire on July 1st, this form, attachments and the fee payment must be received no later than June 1, 2021.

|Name: LEP License #:       |

|Home Address:       |

|City/Town:       State:    Zip Code:      -     |

|Phone:    -   -     |

|Please provide your most current employer information. A list of LEPs and their company name and address will be published and available for public |

|distribution. |

|Present Employer: |

|Business Name:       E-mail address:       |

|Business Address:       |

|City/Town:       State:    Zip Code:      -     |

|Business Phone:    -   -     Ext.       Fax:    -   -     |

Please submit the license renewal fee of $425.00 (check or money order), payable to the Department of Energy & Environmental Protection or “CT DEEP”, with the memo space on the check or money order identifying the payment for "License Renewal Fee-LEP". If providing payment by company check, include the licensee's name in the memo space. A copy of the completed application, a completed Continuing Education Credit Summary Form with attached certificates must be emailed to DEEP.LEPApplicant@ and the original one page completed application and non-refundable renewal fee must be mailed to:

STATE BOARD OF EXAMINERS OF ENVIRONMENTAL PROFESSIONALS

C/O DEPARTMENT OF ENERGY & ENVIRONMENTAL PROTECTION

CENTRAL PERMITS PROCESSING UNIT

79 ELM STREET

HARTFORD, CT 06106-5127

|LICENSEE'S AFFIDAVIT: "I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify|

|that based upon a reasonable investigation, the submitted information is true and complete to the best of my knowledge and belief. I understand that a |

|false statement in the submitted information may be punishable as a criminal offense under section 53a-157b of the General Statutes or any other applicable |

|statute." |

| |       /  /     |

| |LEP # Date |

|Signature of LEP | |

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