RE: Notice of Renewal - Texas Board of Professional ...



Firm Registration Initial Application Form

Please complete this form by typing or printing legibly in ink. This form applies to corporations, partnerships, co-partnerships, joint stock associations, and certain sole proprietors, as specified in TBPG Rule §851.30. Please complete this form and mail it with the applicable fee to the Board at the address indicated above. Complete all sections, marking N/A where applicable. The application fee is non-refundable and must be submitted with the application in the form of a check or money order made payable to the Texas Board of Professional Geoscientists (TBPG).

SECTION I. Firm Legal Name:

DBA (if applicable):

Headquarters Business Address:

Street City State Zip

Main Phone: ( ) Fax: ( ) County:

Hours of Operation: __________________________

Mailing address (if different from headquarters address):

Street or P O Box City State Zip

Professional Geoscientist (P.G.) in responsible charge of geoscience work in Texas at this office:

Name: _________________________ TX P.G. License #: _________ Expiration Date: ____________

Phone: Fax: E-mail:

SECTION II. Registration Fee:

$300 Registration Fee

(Firm, Corporation, Joint Stock Association, Partnership, Co-partnership, or other)

S.O.S. File #: (required for all firms except sole proprietors)*

*Any business operating in Texas under any type, other than a sole proprietorship, is required to obtain a certificate of authority through the Office of Secretary of State (SOS). If operating under a name other than that which is filed with the Secretary of State, an Assumed Name Certificate (or a DBA) must be filed with the County Clerk, and both the SOS number and instrument number must be provided. For more information on obtaining an SOS File number, call the Secretary of State at 512/463-5555.

County Clerk Instrument #: _________________________ (for sole proprietors, as applicable) **

Filed in _____________________ County

**A sole proprietorship is a single individual that operates a business, owns all assets, and is personally liable for all debts. If operating as a sole proprietorship under a name that does not include the sole proprietor’s last name, an Assumed Name Certificate (or a DBA) must be filed with the County Clerk in each county in which the business operates, or offers or performs services. The Assumed Name Certificate instrument number must be provided.

Page 1 of 3

SECTION III. Subsidiary or Branch Offices offering geoscience services to the public in Texas:

(Provide an additional sheet for a list if necessary.) None or N/A

1) Office Name:

City State

Mailing Address:

Street or P O Box City State Zip

Phone: Fax: E-mail: ______________________________

Hours of Operation: __________________________

Professional Geoscientist in responsible charge of geoscience work for Texas in this office:

Name: _____________________________________ Texas P.G. License #:___________________

Phone: Fax: E-mail: ______________________________

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2) Office Name:

City State

Mailing Address:

Street or P O Box City State Zip

Phone: Fax: E-mail: _______________________

Hours of Operation: __________________________

Professional Geoscientist in responsible charge of geoscience work for Texas in this office:

Name: ____________________________________ Texas P.G. License #:____________________

Phone: Fax: E-mail: ______________________________

SECTION IV. Officers or Directors of Business entity (per Board Rule §851.30(c) (2))

An additional sheet or list that includes the following information for each Officer, Director, and/or authorized individual may be provided, if necessary.

Name Business Address City State Zip

Phone: Fax: E-mail: Title:

Name Business Address City State Zip

Phone: Fax: E-mail: Title:

Name Business Address City State Zip

Phone: Fax: E-mail: Title:

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SECTION V. Other P.G.s in responsible charge of geoscience work on behalf of the firm (per Board Rule §851.30(d) and §851.152). An additional sheet and/or attached list may be provided, if necessary.

Name Business Address City State Zip

Business Phone: Current Texas P.G. #:

Name Business Address City State Zip

Business Phone: Current Texas P.G. #:

Name Business Address City State Zip

Business Phone: Current Texas P.G. #:

SECTION VI. Verification of the Authorized Official of the Firm (AOF):

All information submitted herein is true and correct; further, no information has been withheld that might be relevant to this application.

Name of Authorized Official of the Firm (AOF): ____________________________________________

Signature of AOF: __________________________________ Date: ___________________________

Title: Phone: Fax: ______________________

E-mail address: ________________________________________________________________________

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For TBPG use only

Paid $ __________ Check #__________

Firm Registration #: ________________

Date of Registration: ________________

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P.O. Box 13225 • Austin, Texas 78711 • (512) 936-4400 • fax (512) 936-4409

tbpg.state.tx.us

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