Individual Applicants

Individuals

Surveyor Intern Certificate Application

General Information

Please complete all sections of the application.

Applicant Details

Passport Sized Recent Head and Shoulder Photo 2 x 2 inches (51 x 51 mm)
Upload as JPEG

Last Name

First

Middle Name

Suffix

Board records, wall certificate and your seal will reflect first name, middle initial and last name unless another preference is indicated below.

Name Preference

SSN Last 4

Birth Date

NCEES ID

Physical Residence Address

Address 1

Address 2

City

State

Zip

Phone

Mobile

Physical Business Address

Business Name

Address 1

Address 2

City

State

Zip

Phone

Mailing Address

Same as

Residence

Business

Address 1

Address 2

Address 3

City

State

Zip

Experience

http://www.ncbels.org/wp-content/uploads/2019/06/SI-Evidence-of-Experience-Form.pdf

Upload evidence of experience in PDF format below.

Education Information

University/College/School Name:

AAS

PhD

Date of Graduation:

Degree Conferred - (Civil, Surveying, Electrical, etc.)

References

References: Three individuals who are familiar with the applicant's work, character and reputation, one of which must be a Professional Land Surveryor.
Reference forms must be mailed directly to the NC Board office in sealed envelopes with the reference's signature across the back flap.

Name	PE/PLS	Licensed State

Exam

Date FS Exam Taken

State of Exam

Background

Have you previously applied for certification as an SI in North Carolina?

Yes

No
Have you previously applied for certification as an SI or licensure in any other state and been denied?

Yes

No

You must upload details in PDF format below.
Have you ever been disciplined on any professional license?

Yes

No

You must upload details in PDF format below.
Have you ever been convicted of a felony?

Yes

No

You must upload proof of restoration of civil rights in PDF format below.
Have you ever been convicted of a misdemeanor? (Do not include traffic violations.)

Yes

No

You must upload details in PDF format below.
Are you a U.S. citizen?

Yes

No

Provide detailed explanation of legal status in PDF format below.
Does NCEES have an official verified transcript from your educational institution?

Yes

No

The applicant must have the educational institution send an official transcript to the Board either by mail or e-mail (transcripts@ncbels.org).

All information provided is true from my personal knowledge and I understand that any untruthful information may be grounds for denial of certification as a Surveryor Intern.

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