Fillable Printable Corporation Or Limited Liability Company Certificate Of Authorization Application
Fillable Printable Corporation Or Limited Liability Company Certificate Of Authorization Application
Corporation Or Limited Liability Company Certificate Of Authorization Application
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Corporation or Limited Liability Company
Certificate of Authorization
Application
You can use this form to apply for a Certificate of Authorization if you offer
engineering and/or surveying services and are a Corporation, Joint Stock
Association, or Limited Liability Company (LLC).You do not need to apply
if you are a Professional Corporation, Professional Service Corporation, or
Professional Limited Liability Company.
Your application must include:
•A Designated Engineer/ Land Surveyor Affidavit (page 2 of this application)
•A Corporate/ LLC Resolution naming the designated engineer, land surveyor,
or both (page 3 of this application)
Send this completed form and required attachments with a check or money order for $150, payable to the Department of
Licensing, to:
Board of Registration for Professional Engineers and Land Surveyors
Department of Licensing
PO Box 35001
Seattle,WA 98124-3401
Phone: (360) 664-1575
You must also register with Washington’s Secretary of State before a Certificate of Authorization is issued. For requirements,
call (360) 725-0377 or email [email protected].
Applicant
Business name Washington UBI number
Mailing address
City State ZIP code
Person completing application (Area code) Telephone number (Area code) Fax number
Email Types of services offered
Engineering Land surveying Both
Name of designated engineer in responsible charge of Washington engineering activities Washington license number
Name of designated land surveyor in responsible charge of Washington land surveying activities Washington license number
Branch offices in Washington – if applicable(attach additional sheet, if necessary)
Firms with branch offices in Washington are required to designate a currently licensed professional engineer and/or land
surveyor who will be in “responsible charge” for the services offered at the branch location.
Branch office address
Name of person in responsible charge of engineering or land surveying services Washington license number
Branch office address
Name of person in responsible charge of engineering or land surveying services Washington license number
Branch office address
Name of person in responsible charge of engineering or land surveying services Washington license number
Date Signature of corporate / LLC officer or manager
RCW 18.43.130(8); 42.56
ENLS-651-021 (R/1/16)WA Page 1 of 3
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When you have completed this form, please print it out and sign here.
(Professional engineer seal)
(Professional land surveyor seal)
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Designated Engineer/ Land Surveyor Affidavit
I, , the undersigned, on my oath
first being duly sworn, state that I am registered as a professional ,
license number
. On , 20, I was named as the
professional
in responsible charge by a resolution of the Board of
Directors, or company manager(s) of .
I understand that this designation makes me responsible to ensure the firm’s engineering and/or land surveying
activities are in accordance with Washington State law. I further state that I am an employee of said firm and
that I am not designated as the professional in responsible charge for any other firm or business
in the state of Washington. In the event I cease to serve as the
in responsible charge, I shall provide written notice to the Board within 30 days of such change.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
TYPE or PRINT Name of designated professional engineer
Date and place signed Signature of designated professional engineer
TYPE or PRINT Name of designated professiional land surveyor
Date and place signed Signature of designated professional land surveyor
ENLS-651-021 (R/1/16)WA Page 2 of 3
Name of designated professional engineer/ land surveyor
Engineer/ Land surveyor
Date
Engineer/ Land surveyor
Corporation or LLC name
Engineer/ Land surveyor
When you have completed this form, please print it out and sign here.
When you have completed this form, please print it out and sign here.
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Corporation/Limited Liability Company Resolution
On , 20, who is currently licensed as a
professional
in the state of Washington under license number,
was appointed the designated licensee in responsible charge for the practice of engineering and/or land surveying
performed by
.
The designated licensee has full authority to make all final engineering and/or land surveying decisions on behalf
of this firm for such work performed for projects in the state of Washington.
This resolution further states that the bylaws of the corporation or limited liability company agreement shall be
amended in accordance with RCW 18.43.130 pertaining to engineering or land surveying decisions made by the
designee.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
TYPE or PRINT Name of corporation officer or LLC manager
Title
Date and place signed Signature of corporation officer or LLC manager
ENLS-651-021 (R/1/16)WA Page 3 of 3
DateName of designated professional engineer/ land surveyor
Engineer/ Land surveyor
Corporation or LLC name
When you have completed this form, please print it out and sign here.
