Firm Affidavit of Responsibility

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

Firm Affidavit of Responsibility


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.





DO ☐


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



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


Subscribed and sworn, or affirmed, to me this day



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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