RE: Notice of Renewal



Examination Request Form

|Name: | |Birthdate: | |

|Mailing address, + city,| |SSN: | |

|state, zip: | | | |

|E-mail address: | |Phone: | |

Social Security Number: An SSN is required by §231.302 of the Texas Family Code in order to obtain a license and to assist in the collection of child support payments. For more information, please see TBPG rule §851.155 or contact the Texas Attorney General at (512) 460-6000 or (800) 252-8014.

Section I. Military Information.

Are you a U.S. Military Service Member, a Military Veteran, or a Military Spouse? Yes No

If yes, please list dates of applicable Military Service (From/To): _____________________

Please note: Provisions of Texas Occupations Code 55 and TBPG rules may benefit military members, military veterans, and military spouses. Official documentation regarding military status is required.

Section II. Special Accommodations Requests.

Are you requesting special accommodations for the licensing examination? Yes No

If yes, please see Form XIII- Examination Special Accommodations Requests and Requirements.

Section III. Criminal/Administrative Action/Litigation History.

If your answer to any of the questions below is “yes,” please submit a detailed narrative description of the incident or issue and legal documentation (court orders, administrative orders, etc.) that document the final resolution to TBPG.

1) Yes No Has a complaint been filed against you with a professional licensing agency alleging violation of laws or rules pertaining to professional practice?

2) Yes No Has a professional licensing agency found you to be in violation of laws or rules pertaining to professional practice?

3) Yes No Has a professional licensing agency imposed sanctions or other disciplinary action against you?

4) Yes No Have you been arrested?

5) Yes No Are charges pending for any of the above?

6) Yes No Have you been sued for issues involving your professional practice?

Criminal History Evaluation: Texas Occupations Code 53.102 allows applicants with a criminal history to request a criminal history evaluation letter from TBPG regarding his/her eligibility for a license before taking a licensing examination.

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Section IV. Exam Information.

Please select which exam(s) you wish to take and submit the request and required documentation to TBPG.

ASBOG® Fundamentals of Geology Exam- required for GIT cert and/or PG license

|Requested exam date: | |

Please include the following items with your request:

Sealed official academic transcripts

$25 exam administrative fee, payable to TBPG

**Note: Once an applicant is approved to sit for the Fundamentals exam, a $200*

examination fee is required and payable to ASBOG®; details for payment will be provided. _______________________________________________________________________________________

ASBOG® Practice of Geology Exam- required for PG license

Please include the following items with your request:

|Requested exam date: | |

Application for P.G. license (Form A)

Sealed official academic transcripts

$25 exam administrative fee, payable to TBPG

$255 license application fee, payable to TBPG

**Note: Once an applicant is approved to sit for the Practice exam, a $250 examination fee is required and payable to ASBOG®; payment details will be provided.

_______________________________________________________________________________________

Texas Geophysics Exam- required for GIT cert and PG license

Please include the following items with your request:

|Requested exam date: | |

GIT applicants must submit the following items:

Application for GIT (Form H)

Sealed official academic transcripts

$200 fee ($25 administrative fee and $175 exam fee, payable to TBPG)

$25 GIT application fee, payable to TBPG

PG applicants must submit the following items:

Application for P.G. License (Form A)

Sealed official academic transcripts

$200 fee ($25 administrative fee and $175 exam fee, payable to TBPG)

$255 license application fee, payable to TBPG

_______________________________________________________________________________________

Please submit all exam request materials to: TBPG, PO Box 13225, Austin, TX 78711

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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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