Firm Affidavit of Responsibility BOARD USE ONLY 3012
Complete a separate Firm Affidavit of Responsibility for each Ohio professional engineer and/or professional surveyor who is designated in responsible charge. Affidavits of responsibility must accompany all Certificate of Authorization applications, including biennial renewals.
Name of Ohio P.E. and/or P.S. Registrant Designated in Responsible Charge
Ohio P.E. No.
Ohio P.S. No.
DO NOT ☐
have other engineering/surveying employment or provide engineering and/or surveying services outside of this firm. *If affirmative, attach an explanation.
IMPORTANT- All information listed must be completed or the application will be returned. Signatures, dates, and notary seal must be original; scanned signatures and copies are not accepted.
I, [printed name], being the duly sworn or affirmed affiant, state I am a registered professional engineer and/or registered professional surveyor in the state of Ohio as indicated above; that I am a full-time employee of the above-named firm, in accordance with Ohio A.C. 4733-39-02(B); that I am in responsible charge for and in charge of the professional engineering and/or professional surveying activities and decisions of this firm; and that I meet the requirements pursuant to Ohio Revised Code Chapter 4733 for such designation. In addition, I understand that if a Temporary Certificate of Authorization Permit is granted, it is only valid for 90 days from the date of issuance. Should the Board disapprove the firm’s application for a Certificate of Authorization, the temporary permit shall terminate on the date of denial and the firm will cease and desist from practicing or offering engineering and/or surveying service in the state of Ohio.