Application to Renew Environmental Professional's License



STATE BOARD OF EXAMINERS OF ENVIRONMENTAL PROFESSIONALS

APPLICATION FOR A NEW

ENVIRONMENTAL PROFESSIONAL'S LICENSE

for DEEP use

(date stamp)

Pursuant to section 22a-133v-4(e) of the Regulations of Connecticut State Agencies, this application and $1,062.50 fee must be received by the DEEP on behalf of the Board within six months of the expiration of your license. Since your license expired on July 1st, this document and fee payment must be received on or before December 31st of the same year your license expired.

|Name: Expired 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 a written request for a new license, this application form and the fee of $1,062.50 (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 the "New License Fee-LEP". If providing payment by company check, include applicant’s name in the memo space. The application and non-refundable fee shall 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

|APPLICANT’S AFFIDAVIT:"I 00:00:00 Z1970-01-01 00:00:00 Z1970-01-01 00:00:00 Z[?] certify under penalty of perjury that I have not affixed my seal, or |

|allowed my seal to be affixed to any document following the expiration of my license. I shall not present myself to be an LEP and shall not perform |

|professional services as an LEP. I have personally examined and am familiar with the information submitted in this document and any attachments thereto, |

|and I certify 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." |

| | |

| |  /  /     |

| |Date |

|Signature of applicant | |

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