Blank Ohio 4011 D PDF Form

Blank Ohio 4011 D PDF Form

The Ohio 4011 D form is the application required for the renewal of dual professional engineer (P.E.) and professional surveyor (P.S.) licenses in Ohio for the 2012-2013 period. It is essential to complete this form accurately and submit it by the deadline to maintain your licensure. For a smoother renewal process, consider filling out the form online by clicking the button below.

The Ohio 4011 D form serves as a critical document for professional engineers and surveyors seeking to renew their dual P.E. (Professional Engineer) and P.S. (Professional Surveyor) licenses for the 2012-2013 period. This application must be completed accurately and submitted by the specified deadline to ensure continued licensure. Applicants are reminded that they can expedite the renewal process by utilizing the online platform available at www.peps.ohio.gov. It is essential to note that the form is not intended for reinstatement purposes; those needing to reinstate their licenses should contact the Board directly for guidance. To qualify for renewal, applicants must confirm they have completed the required 15 hours of continuing professional development, as outlined in section 4733.151 of the Ohio Revised Code. The form also includes sections for name and address changes, which require appropriate legal documentation. Additionally, applicants must disclose any felony convictions or other legal issues that may affect their registration status. A signature certifying the accuracy of the information provided is required, along with the appropriate renewal fee. Failure to comply with these stipulations may result in delays or denial of the renewal application.

Document Sample

OHIO’S STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS BOARD USE ONLY

4011-D

2012-2013 Ohio Dual P.e., P.S. License

 

renewal Application

 

reMINDer! For faster license renewal, renew online at www.peps.ohio.gov.

DO NOt SUBMIt application if continuing professional development require- ments are not complete in accordance with section 4733.151 of the Ohio R.C.

NAMe AND ADDreSS reQUIreD

NAME

 

 

P.e. AND P.S. NUMBerS reQUIreD

 

 

 

PE–

 

 

PS–

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$80.00 DUe NOW

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

AMOUNT DUE After 12/31/2011: $120.00

CITY

STATE ZIP CODE

Make your check or money order payable in U.S.

 

 

 

 

 

 

funds to treasurer, State of Ohio.

 

 

 

NAMe cHANGe AND/Or cHANGe Of ADDreSS ONLy

NAME CHANGE reQUIreS LeGAL DOcUMeNtAtION

ADDRESS

ADDRESS

CITY

STATE

ZIP CODE

 

 

 

OHIO COUNTY reQUIreD If OHIO ADDreSS

I do not plan to renew at this time.

IMPOrtANt — DO NOt USe tHIS

fOrM fOr reINStAteMeNt!

this application cANNOt be used for reinstatement of a professional license. It is to be used for 2012-2013

P.E., P.S. renewals only. Email the Board, at pes.board@ pes.ohio.gov, for reinstatement instructions.

DO NOt SUBMIt copies of continuing professional development information with this application.

yeS NO I certify that I have completed 15 continuing professional development hours in accordance with section 4733.151

of the Ohio Revised Code Or I’m exempt from this requirement because I was granted initial registration during calendar year 2011.

If you answered NO to this question, DO NOt submit this renewal application.

FOR MORE INFORMATION REGARDING THE CPD REQUIREMENT, CPD AUDIT, AND DOWNLOADING CPD ACTIVITY LOGS, VISIT OUR WEBSITE AT www.peps.ohio.gov.

yeS NO Since your last renewal have you been convicted of or pleaded guilty to any felony or crime involving moral turpitude or had your registration revoked, voluntarily surrendered or suspended by another jurisdiction? If yeS, please give date, type of conviction, court of conviction, case number, and explanation.

ATTACH SEPARATE SHEET IF NEEDED

I certIfy that this is a properly completed and accurate license renewal application which I am submitting to the state of Ohio’s State Board of Registration for Professional Engineers and Surveyors. I have not omitted any requested information. I

understand that my renewal is contingent upon satisfactory completion of all requirements. I further understand that any person who knowingly makes false statements on the renewal application is guilty of falsiication under section 4733.20 of the Ohio

Revised Code, and subject to penalties under law.

Applicant Signature

2012-2013 DUAL Pe PS LIceNSe reNeWAL

STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND SURVEYORS

50 W BROAD ST STE 1820 COLUMBUS OH 43215-5905

Date Signed

Make check or money order payable in U.S. funds to treasurer, State of Ohio. Cash is not accepted. for credit card payment, renew online. Send completed, signed, and dated application and fee; postmarked no later than 12/31/2011; to the Board address at left.

PES 4011-D (Rev. 10/2011) 1020

Page 1 of 1

File Specifics

Fact Name Details
Form Purpose The Ohio 4011 D form is used for the renewal of Dual Professional Engineer (P.E.) and Professional Surveyor (P.S.) licenses for the years 2012-2013.
Governing Law This form is governed by section 4733.151 of the Ohio Revised Code.
Fee Structure The renewal fee is $80.00 if submitted by 12/31/2011. After this date, the fee increases to $120.00.
Continuing Education Requirement Applicants must complete 15 hours of continuing professional development or claim an exemption if registered in 2011.
Submission Instructions Completed forms must be postmarked by 12/31/2011 and sent to the State Board of Registration for Professional Engineers and Surveyors.

How to Use Ohio 4011 D

Completing the Ohio 4011 D form is an important step for professionals looking to renew their licenses. After filling out the form, ensure that you submit it along with the appropriate fee before the deadline. Follow these steps carefully to ensure your application is processed smoothly.

  1. Begin by entering your name and address in the designated fields at the top of the form.
  2. Fill in your Professional Engineer (P.E.) and Professional Surveyor (P.S.) numbers in the required sections.
  3. Indicate your current address, including city, state, and zip code.
  4. Check the appropriate box to confirm whether you plan to renew your license at this time.
  5. If applicable, indicate any name change or change of address, and provide legal documentation for a name change.
  6. Certify that you have completed 15 continuing professional development hours or indicate your exemption if you were granted initial registration during the calendar year 2011.
  7. Answer the question regarding any felony convictions or disciplinary actions since your last renewal. If you answer "Yes," provide the necessary details on a separate sheet if needed.
  8. Sign and date the application to certify that all information is accurate and complete.
  9. Prepare your payment. Make a check or money order payable in U.S. funds to the "Treasurer, State of Ohio." Remember that cash is not accepted.
  10. Mail the completed, signed, and dated application along with the fee to the State Board of Registration for Professional Engineers and Surveyors, ensuring it is postmarked no later than 12/31/2011.

Your Questions, Answered

What is the Ohio 4011 D form used for?

The Ohio 4011 D form is specifically designed for the renewal of Dual Professional Engineer (P.E.) and Professional Surveyor (P.S.) licenses in Ohio. It serves as an application to ensure that licensed professionals maintain their credentials and comply with state regulations.

What are the fees associated with the Ohio 4011 D form?

For timely renewal, the fee is $80. However, if the application is submitted after December 31, 2011, the fee increases to $120. It is important to note that payments must be made in U.S. funds via check or money order, payable to the Treasurer, State of Ohio. Cash payments are not accepted.

What are the continuing professional development (CPD) requirements?

Applicants must complete 15 hours of continuing professional development in accordance with section 4733.151 of the Ohio Revised Code. If an applicant was granted initial registration during the calendar year 2011, they may be exempt from this requirement. It is essential to certify that these hours have been completed when submitting the form.

Can I use the Ohio 4011 D form for reinstatement of my license?

No, the Ohio 4011 D form is not intended for license reinstatement. If you need to reinstate your license, you should contact the Board directly at [email protected] for specific instructions on how to proceed.

What should I do if I have a name or address change?

If you have a name change, you will need to provide legal documentation to support this change. For an address change, simply fill in the new address on the form. Ensure that you provide complete and accurate information to avoid any issues with your renewal.

What happens if I do not meet the renewal requirements?

If you do not meet the renewal requirements, such as failing to complete the necessary continuing professional development hours, you should not submit the renewal application. Doing so could result in penalties, including the possibility of having your license not renewed. It’s best to ensure all requirements are fulfilled before submitting your application.

Common mistakes

  1. Failing to complete the continuing professional development requirements. Applicants must ensure they have met the 15-hour requirement before submitting the form.

  2. Not providing legal documentation for name changes. If an applicant has changed their name, they must attach the necessary legal documents to support this change.

  3. Incorrectly filling out the license numbers. It's crucial to accurately enter both the P.E. and P.S. numbers to avoid processing delays.

  4. Submitting the application without payment. The correct fee must accompany the application. Applications submitted without payment will not be processed.

  5. Using the form for reinstatement purposes. This application is specifically for renewal only, and applicants should not use it if they need to reinstate a license.

  6. Omitting required information. Every section of the application must be filled out completely. Incomplete applications may be rejected.

Documents used along the form

The Ohio 4011 D form is a crucial document for renewing professional engineering and surveying licenses in Ohio. Along with this form, several other documents are commonly utilized in the renewal process. Below is a list of these forms and their brief descriptions.

  • Ohio CPD Activity Log: This document tracks the continuing professional development hours completed by the licensee. It is essential for demonstrating compliance with the CPD requirements.
  • Verification of Employment: A form that confirms the employment status of the licensee, often required to validate the practical experience necessary for license renewal.
  • Legal Documentation for Name Change: If the applicant has changed their name, legal documents such as a marriage certificate or court order must be submitted to validate the change.
  • Reinstatement Application: For those who have allowed their license to lapse, this form is necessary to apply for reinstatement. It is not to be confused with the renewal application.
  • Payment Receipt: A receipt confirming payment of the renewal fee. This is important for record-keeping and may be required to prove that the fee was paid on time.
  • Felony Disclosure Form: If applicable, this form is used to disclose any felony convictions or disciplinary actions that may affect the license renewal process.
  • Continuing Education Certificates: Certificates from completed courses that contribute to the required CPD hours. These are not submitted with the renewal application but must be kept on file in case of an audit.

Each of these documents plays a vital role in ensuring a smooth renewal process for professional engineers and surveyors in Ohio. It is important to gather all necessary paperwork promptly to avoid delays in license renewal.

Similar forms

The Ohio 4011 D form is similar to the Texas Professional Engineer License Renewal Application. Both documents serve as official requests for the renewal of professional engineering licenses. They require the applicant to provide personal information, including name, address, and license numbers. Additionally, both forms stipulate the necessity of completing continuing education requirements to qualify for renewal. The Texas application also includes a certification section, where applicants affirm their compliance with all renewal prerequisites, mirroring the Ohio form's emphasis on accuracy and honesty in the renewal process.

Another comparable document is the California Professional Engineer License Renewal Application. Like the Ohio 4011 D form, this application necessitates that engineers confirm their completion of continuing education hours. Both forms require applicants to disclose any legal issues that may affect their professional standing, such as felony convictions or license suspensions. Furthermore, both documents provide clear instructions for submitting the application and associated fees, ensuring a structured renewal process.

The Florida Professional Engineer License Renewal Application shares similarities with the Ohio 4011 D form as well. Both documents require a renewal fee and emphasize the importance of fulfilling continuing education requirements. The Florida application also asks for personal information and any updates regarding the applicant's legal status. This parallel highlights the common regulatory framework governing professional engineers across states, ensuring that all applicants maintain a standard of competence and ethical conduct.

The New York Professional Engineer License Renewal Application is another document akin to the Ohio 4011 D form. Both applications demand personal details, including the engineer's license number and contact information. They also require a declaration of completed continuing education credits, reinforcing the commitment to ongoing professional development. Additionally, the New York form includes questions regarding any criminal history, similar to the inquiries found in the Ohio application, ensuring that all applicants meet the necessary moral and legal standards for licensure.

The Illinois Professional Engineer License Renewal Application is comparable to the Ohio 4011 D form in several respects. Both documents require engineers to provide their license number and personal information. They also mandate the completion of continuing education hours as a prerequisite for renewal. Furthermore, both applications include a section where applicants must certify the accuracy of their submissions, underscoring the importance of integrity in the renewal process.

Lastly, the Pennsylvania Professional Engineer License Renewal Application resembles the Ohio 4011 D form. Both forms require applicants to verify their continuing education compliance and disclose any legal issues that may impact their licensure. They also request personal information, such as name and address, and emphasize the submission of accurate and complete information. This similarity illustrates the shared regulatory expectations among states for maintaining professional engineering standards.

Dos and Don'ts

When filling out the Ohio 4011 D form, it is essential to follow specific guidelines to ensure a smooth renewal process. Below is a list of actions to take and avoid.

  • Do submit the application only if all continuing professional development requirements are complete.
  • Do provide your full name, address, and license numbers clearly on the form.
  • Do ensure that the application is signed and dated before submission.
  • Do make your payment in U.S. funds using a check or money order made out to the Treasurer, State of Ohio.
  • Don't submit copies of your continuing professional development information with the application.
  • Don't use this form for reinstatement of your professional license.
  • Don't submit the application if you have not completed the required 15 continuing professional development hours.
  • Don't forget to check for any felony convictions or moral turpitude issues since your last renewal.

By adhering to these guidelines, you can help ensure that your renewal application is processed efficiently and without unnecessary delays.

Misconceptions

Understanding the Ohio 4011 D form is crucial for professionals seeking to renew their licenses. However, several misconceptions can lead to confusion. Here are seven common misunderstandings:

  • It can be used for reinstatement. This form is specifically for license renewal and cannot be used for reinstatement of a professional license.
  • Submitting copies of continuing education documents is necessary. You should not submit copies of your continuing professional development information with the application.
  • Late fees are not applicable. If you miss the renewal deadline, the fee increases from $80 to $120 after December 31, 2011.
  • Online renewal is not an option. For faster processing, you can renew your license online at the Ohio Board's website.
  • All applicants are automatically exempt from continuing education. Only those who were granted initial registration during 2011 are exempt from the continuing professional development requirement.
  • Address changes do not require documentation. A legal document is necessary for any name change, while address changes must be properly noted on the form.
  • Felony convictions do not need to be reported. If you have been convicted of a felony or a crime involving moral turpitude, you must disclose this information on the application.

Being aware of these misconceptions can help ensure a smoother renewal process for your professional license in Ohio.

Key takeaways

Here are key takeaways regarding the Ohio 4011 D form for dual P.E. and P.S. license renewal:

  • Online Renewal Option: For faster processing, consider renewing your license online at www.peps.ohio.gov.
  • Application Submission: Do not submit the application if you have not completed the required continuing professional development hours.
  • Fees: The renewal fee is $80. If submitted after December 31, 2011, the fee increases to $120.
  • Legal Documentation: If changing your name, you must provide legal documentation to support the change.
  • Exemption Clause: If you were granted initial registration during 2011, you may be exempt from the continuing professional development requirement.
  • No Reinstatement: This form cannot be used for reinstating a professional license. Contact the Board for reinstatement instructions.
  • Continuing Professional Development: You must certify completion of 15 hours of continuing professional development unless exempt.
  • Accurate Information: Ensure that all information provided is accurate. False statements can lead to penalties.

Be sure to send your completed application, along with payment, to the specified Board address by the deadline.