DATE RECEIVED
Oregon State Board of Examiners for Engineering and Land Surveying 670 Hawthorne Ave. S.E., Suite 220 Salem, Oregon 97301 Telephone: (503) 362-2666 E-mail: osbeels@osbeels.org
FOR OFFICE USE ONLY
ID NUMBER: ____________
PAID: __________________
PROFESSIONAL APPLICATION BY EXAMINATION
Exam Date: Please indicate exam date.
SPRING EXAM
FALL EXAM
ORIGINAL AND COMPLETED APPLICATION MUST BE POSTMARKED BY THE POSTMARK DEADLINE. THERE ARE NO EXCEPTIONS.
Exam: Please check the appropriate box for exam type. Initial Professional Engineering Examination Professional Engineer Discipline: __________________________________ Initial Professional Land Surveying Examination Payment Type: NOTE: The applicant is responsible for reviewing the requirements for admittance to an exam. Please carefully read the Oregon laws and rules as application fees are non-refundable (OAR 820-010-0300). CREDIT CARD NO. EXP. DATE CHECK / MONEY ORDER
(Make checks & money orders payable to OSBEELS)
___________________________
_______
Accepted Cards: Visa, Mastercard, Discover, & American Express
CASH
NOTE: ALL fees must be paid in full prior to the review process. You will not be scheduled for any exam until your application is complete (all verifications, transcripts, etc.) and approved by the Board office. Application fees are non-refundable (OAR 820-0100300). GENERAL INFORMATION Please mail all correspondence to:
First Name
Residential
Business
Middle Name or Initial, as it should appear on certificate
1. Full Legal Name Last Name (Jr., II, etc.)
2. Birth Date
3. Social Security Number ______ - _______ - ______
If you are a foreign citizen unable to obtain a United States Social Security Number, please read the last page of the application or contact the Board office for further information. Home Phone
4. Residential Mailing Address
Apartment No.

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