Fillable Printable Professional Engineer Registration Application
Fillable Printable Professional Engineer Registration Application
Professional Engineer Registration Application
Professional Engineer
Registration Application
Send this completed form and your fee in a check or money order payable to
the Department of Licensing to: Professional Engineers and Land Surveyors,
Department of Licensing, PO Box 35001, Seattle WA 98124-3401
Application type (check one)
by Exam – $65
by Comity – $110
Applicant
PRINT or TYPE Name (Last, First, Middle – will appear in the proper order on your wall certificate) Former name (If applicable)
Social Security number required* (or ITIN, Green Card, Canadian SIN)
Date of birth Gender
Male Female
Mailing address
City State ZIP code
Present position Business name
Business location address
City State ZIP code
(Area code) Contact telephone number Email
Branch of engineering
Answer the following
If you answer “Yes” to any of these questions, attach a detailed explanation.
1. In this state or any other jurisdiction, are you or have you
:
a. Within the last 10 years, had any action (fine, suspension, revocation, censure, surrender, etc.)
taken against any professional or occupational license, certification, or permit held by you?.........
Yes No
b. Within the last 10 years, defaulted or been convicted of or entered a plea of no contest to a
gross misdemeanor or felony crime? (Don’t include traffic offenses.) ...........................
Yes No
2. Are you having a NCEES experience record sent? ......................................... Yes No
If yes, please provide NCEES record number:
3. Do you authorize any business associates (past and present) and any governmental agencies
(local, state, or federal) to release to the Department of Licensing any information, files, or records
which may be required for a background investigation? ..................................... Yes No
4. Do you understand that if you provide any false information in this application we may deny,
suspend, or revoke your license to practice in Washington? .................................. Yes No
*All United States applicants are required by federal and state law to provide their Social Security number (SSN) for use in child support enforcement
programs (42 U.S.C. 666(a)(13) and RCW 74.20A.320). It may also be used for education loan repayment programs and identification of records with similar
names. Submission of your SSN is mandatory; failure to submit it may result in denial of your application.
Education
Name and location of colleges, universities,
technical schools attended
Dates of attendance
From To Curriculum Degree/ Date
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Applicant name
Previous and current registration
Answer the following
Have you filed an application with this office within the last five years?............................ Yes No
If yes, certificate number
Written FE exam in state of NCEES exam? Yes No
Written PE exam in state of NCEES exam? Yes No
State where you got your first license
State where you are currently licensed
• Go online to account.ncees.org and follow the instructions to request license/exam verification.
• If your state board is not listed on this site, contact them to request verification be sent to us.
Engineer references
List five references (not relatives), at least three of which are registered professional engineers, having personal
knowledge of your character and professional reputation.
Name Position Email
(Area code) Telephone
Certificate number/State
Experience record summary
Please list all of your employers beginning with the most recent. You must account for all time since leaving college (if
applicable) or beginning your engineering career to now. You must also include periods while in school, unemployed, or
non-engineering work. Attach additional sheets if necessary.
• For full time employment of 32 or more hours/week indicate “FT.” For part time under 32 hours/week indicate “PT.”
• If the work is not to be verified, indicate “No.” Any experience not verified will not be counted toward the experience requirement.
Time period (begin with most recent)
From (month-year) To (month-year) Employer
Full time or
part time?
To be verified?
(yes or no)
1
2
3
4
5
6
7
8
9
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Applicant signature
Date and place
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When you have completed this form, please print it out and sign here.
