Application for Professional Engineer, Professional ...

Bureau of Professional Licensing PO Box 30670 Lansing, MI 48909

Telephone: (517) 241-9288 bpl

BPLHelp@

PROFESSIONAL ENGINEER, PROFESSIONAL SURVEYOR, OR

ARCHITECT RELICENSURE APPLICATION

(This Form Should Not Be Used For License Renewal)

Authority: 1980 PA 299, MCL 338.3434a

Legal Name (First, Middle, Last)

Date of Birth

U.S. Social Security Number

Address

City

State

Zip Code

Permanent I.D. Number

Telephone Number

E-Mail Address

I have the ability and will serve the public in a fair, honest and open manner. If I have had a judgment of guilt in a criminal proceeding or a civil action against me, I am rehabilitated or the substance of my former offense is not reasonably related to the occupation or profession for which I am seeking a license.

Yes

No

Do you have any unsatisfied penalties or conditions imposed by disciplinary action in this state or any other jurisdiction?

Yes

No

Applicants whose license has been expired for LESS than 3 years

Architect: Submit proof of not less than 24 hours of continuing education that was completed during the 2-year period immediately preceding the date of relicensure. The continuing education must be in activities approved under administrative rule R 339.15502 and must cover health, safety, and welfare subjects approved under administrative rule R 339.15506.

Professional Engineer and Professional Surveyor: Submit proof of completing not less than 15 hours of continuing education that was completed during the 12 months immediately preceding the date of the application for relicensure.

Applicants whose license has been expired for MORE than 3 years

Architect, Professional Engineer and Professional Surveyor: Must meet all of the applicable education, examination, and experience requirements currently required for licensure under MCL 339.2004 and administrative rules promulgated by the department. The applicant must produce the records required for demonstrating he or she satisfies the current requirements at the request of the department. Architect relicensure applicants must submit proof of not less than 24 hours of continuing education that was completed during the 2-year period immediately preceding the date of relicensure. The continuing education must be in activities approved under administrative rule R 339.15502 and must cover health, safety, and welfare subjects approved under administrative rule R 339.15506.

Certification

I certify that the statements in this document are true and complete. I understand that any omitted statement, misrepresentation, or fraud may be cause for denial of my application, disciplinary action, or may be punishable by law. I agree the Department is required by law to obtain my social security number pursuant to MCL 338.3434a.

Signature CHECK THE LICENSE/REGISTRATION TYPE

Professional Engineer Relicensure Professional Surveyor Relicensure Architect Relicensure

$ 95.00 $105.00 $ 85.00

6201-06 4001-06 1301-06

Date FOR OFFICE USE ONLY

License Number

Issue Date

Make your check or money order in U.S. Currency payable to: STATE OF MICHIGAN

FEES ARE AUTHORIZED BY THE STATE LICENSE FEE ACT, 1979 PA 152 AND ARE NOT REFUNDABLE.

LARA/BPL-DBRELIC (Rev. 03/20)

The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.

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