COLORADO VERIFICATION OF PROFESSIONAL LAND SURVEYOR LICENSURE Applicant: Complete Part 1 and forward this form to the State Board verifying your records. Include a stamped envelope addressed to Colorado Division of Professions and Occupations, Office of Licensing—Professional Land Surveyors, 1560 Broadway, Suite 1350, Denver, CO 80202. Check with the State Board to determine if it charges a fee for processing these requests. Contact information for state boards is available at www.ncees.org. Note: It is permissible for the Colorado Board to receive the verification before receiving your application and fee.

Part 1—To be completed by the APPLICANT Name: Last

First

Middle

Suffix

My name should appear in your records as: Social Security Number: Mailing Address:

Date of Birth: PO Box, Street: City, State, Zip:

Professional Land Surveyor License Number:

Date Issued:

Land Surveyor Intern Certificate Number:

Date Issued:

License verification fee enclosed in the amount of: $ Applicant Signature:

Date:

Verifying State Board: Complete Part 2 and send the completed form directly to Colorado Division of Professions and Occupations, Office of Licensing—Professional Land Surveyors, 1560 Broadway, Suite 1350, Denver, CO 80202.

PART 2—To be completed by the VERIFYING STATE BOARD From (Verifying State Board Name): State Board Address:

Date:

PO Box, Street: City, State, Zip:

A. This Individual was licensed as: License Type

License Number

Issue Date

Valid Until

Land Surveyor Intern Professional Land Surveyor B. Basis of Licensure: Hours 1.

Score

NCEES

Other

Exam Date

Written Examination FS PS

2.

Do you accept the minimum passing scores as recommended by NCEES?

3.

LSI Accepted From:

4.

Licensed by Education and Experience:

5.

Other (Explain):

YES

NO

YES

NO

PLS Accepted From: Years of Education:

Years of Experience:

C. Disciplinary Action: Has disciplinary action ever been taken against this applicant? If YES, give details of the board action:

Verified By: STATE BOARD SEAL Title:

Date: