Firm Affidavit of Responsibility



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Ohio’s State Board of Registration for Professional Engineers and Surveyors



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.




  1. Current Ohio Certificate of Authorization number- *REQUIRED unless a new firm

.



  1. Firm Name

    Firm Name –Must be the same as the firm’s Certificate of Authorization




    .







  2. Ohio Registrant Designated in Responsible Charge

Name of Ohio P.E. and/or P.S. Registrant Designated in Responsible Charge

Ohio P.E. No.

Ohio P.S. No.

.

.

.

I

DO ☐

DO NOT ☐

have other engineering/surveying employment or provide engineering and/or surveying services outside of this firm. *If affirmative, attach an explanation.




  1. Notarized Affidavit

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.


State of

County of







}SS.

AFFIANT

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.

Affiant signature

Printed Affiant Title

Date Signed










NOTARY




Subscribed and sworn, or affirmed, to me this day




of




,







Witness my hand and seal hereon

Notary signature

My commission expires










State Board of Registration for

Professional Engineers and Surveyors

77 S High St, Ste 2472

Columbus, Ohio 43215




PES 3012 (Rev. 04/2016)


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