LY-EX.indd

Packet updated 4/19/24

DPR-I-LY -- Instructions Revised 7/23

Important Information:

 We recommend that you review the Education, Examination and Experience requirements prior to

applying, which can be found at: https://www.idfpr.illinois.gov/profs/LandSurv.html

 An application is active for three years from the date of receipt by the Department.

Abbreviations used in this document:

- National Council of Examiners for Engineering and Surveying (NCEES)

- Continental Testing Services, Inc. (CTS)

- Professional Land Surveyor (PLS)

- Surveyor Intern (SI)

- Fundamentals of Surveying Exam (FS)

- Principles and Practice of Surveying Exam (PS)

- Illinois Jurisdictional Exam (IJ)

PROFESSIONAL DESIGN FIRM REQUIREMENT

Any company that oﬀ ers professional services in Illinois must be registered as a Professional Design Firm (PDF)

with this Department. Professional services include: Architecture, Professional Engineering, Structural

Engineering, and/or Land Surveying. Oﬀ ering services without a PDF registration is a violation of each of

the four design profession Acts and subject to discipline by the Department. Applicants are encouraged to

advise a company principal of this requirement.

You may review the requirements here: https://idfpr.illinois.gov/content/dam/soi/en/web/idfpr/renewals/apply/

forms/f1419lt.pdf

EXAM APPROVAL

Application to the Department is no longer required for exam approval.

Surveyor Intern candidates may register for the FS exam at any time with NCEES at www.NCEES.org.

Professional Land Surveyor candidates may register for the PS exam at any time with NCEES at

www.NCEES.org and the IJ exam with CTS at www.continentaltesting.org.

Once you have gained the required education, passed the applicable examination(s), and gained the applicable

experience (for license candidates), submit your application to the Department for review by the Board.

APPLICATION FOR:

ENROLLED SURVEYOR INTERN

PROFESSIONAL LAND SURVEYOR LICENSE

Professional Land Surveyor - Page 2

EDUCATION:

There are two (2) types of Baccalaureate degrees that are accepted under the Land Surveyor Practice Act. Note,

the educational requirement is based upon a Baccalaureate degree, not a post-graduate degree.

 Baccalaureate degree in Land Surveying with 24 hours of LS coursework - Approved Program.

(Section 1270.14 of the Administrative Rules).

 Baccalaureate degree with 24 hours of LS coursework.

(Section 1270.15 of the Administrative Rules).

 Include oﬃ cial descriptions for land surveying courses to be reviewed by the Board for possible acceptance.

 Acceptable coursework to satisfy the 24 hour requirement includes, but is not limited to; fundamentals

of land surveying, boundary surveying, route surveying, topographic surveying, descriptions, legal aspects,

subdivision design, data computations and adjustments, map projections and geometric geodemy and

photogrammetry. Note: the Board may also credit an advanced "CAD" course in this category.

Foreign Educated Applicants:

 NCEES Credential Evaluation. If your Baccalaureate degree was earned outside the United States, an

NCEES Credential Evaluation of the Baccalaureate degree is required, pursuant to Section 1270.5 & 1270.10

of the Administrative Rules. The educational courses must meet Illinois speciﬁ c requirements, which may diﬀ er

from the NCEES standard.

Here is the link to start the process: https://ncees.org/ncees-services/credentials-evaluations

 TOEFL-iBT Exam. If your Baccalaureate courses were not taught in English; as indicated on your NCEES

evaluation, you are required to provide proof of passage of the TOEFL-iBT, pursuant to Section 1270.5 &

1270.10 of the Administrative Rules. Here is the link to take the TOEFL exam: http://www.ets.org

EXAMINATION:

Pursuant to Section 1270.20 of the Administrative Rules, there are three examinations that are currently

administered and accepted for the Land Surveyor profession:



 For enrollment as an Surveyor Intern: NCEES - FS Examination

 For licensure as a Professional Land Surveyor: NCEES - FS, PS and the State IJ examinations.

Note: Applicants for licensure who passed the national exams outside Illinois must still have the required

experience by Illinois law prior to being approved to sit for the IJ examination to be licensed.

EXPERIENCE:

Review Section 1270.13 of the Administrative Rules for acceptable experience requirements.

Land Surveyor License:

1. Four (4) years of land surveying experience in Responsible Charge is required for all applicants.

SURVEYOR INTERN AND LICENSE QUALIFICATIONS

Professional Land Surveyor - Page 3

Enrollment is based on education and examination.

MINIMUM REQUIREMENTS:

 Education meeting one of the requirements as shown on page two.

 Successful passage of the FS examination.

Upon successful passage of the FS exam and after your score information has been received by the Department,

you will receive an email from the Department with a link to download your SI certiﬁ cate.

ENROLLMENT AS A SURVEYOR INTERN

LICENSURE AS A PROFESSIONAL LAND SURVEYOR

Approval of licensure is based on education, examination and experience.

MINIMUM REQUIREMENTS:

 Education meeting one of the requirements as shown on page two.

 Successful passage of the FS and PS examinations.

 Required Land Surveying experience as shown on page two.

 All applicants for licensure must successfully pass the IJ examination (after meeting experience requirement).

APPLICATION INSTRUCTIONS

IMPORTANT:

This application is used by the Department for over 100 professions. Not all portions may apply. Before

completing the application, read these instructions and then follow the directions as they apply to your speciﬁ c

situation. This will assist you in accurately completing your application and eliminate any delay in processing.

There are ﬁ ve steps to compete in order for your application to be reviewed.

Step I - Complete the four-page Application for Licensure/Examination using the below parts:

Part I - APPLICATION CATEGORY INFORMATION AND FEES.

Part IA. Select this ONLY if you are a current military service member/spouse.

Part IB. Use the chart below to complete PART IB 1- 4 of the application to select your method of application.

Use the rows to locate the exam or method of licensure you are applying for.

Profession Name:

Profession

Code

Licensure Method

Fee

Surveyor Intern

Professional Land Surveyor

028

035

Acceptance of Examination

Endorsement of License

$70

$150

Professional Land Surveyor - Page 4

Part II - APPLICANT IDENTIFICATION INFORMATION.

All applicants must complete this section. If the name shown on your supporting documents is diﬀ erent from that

shown on your application, you must submit PROOF OF LEGAL NAME CHANGE; (i.e. copy of marriage license,

divorce de-cree, aﬃ davit or court order). A valid email address is required to receive all department

notiﬁ cations, license download link and renewal notices. If you do not have a U.S. Social Security Number,

contact the Department for the appropriate aﬃ davit form.

Part III - EDUCATION INFORMATION.

All applicants (except those submitting an NCEES Record) must complete this section. All applicants must submit

an oﬃ cial transcript from each college listed on the application unless contained in your NCEES Record or

Credential Evaluation.

Part IV - RECORD OF LICENSURE INFORMATION.

Only applicants that currently hold an SI/SIT certiﬁ cate or Land Surveyor license/registration in another U.S.

jurisdiction must complete this section. List ONLY the active SI/SIT certiﬁ cate or license(s) you hold.

Part V - RECORD OF EXAMINATION.

Only applicants that have taken an exam must complete this section. Applicants must verify that they have taken

and passed each appropriate examination. Review page two for the required examination(s). DO NOT LIST

FAILED EXAMINATIONS, ONLY LIST EXAMINATION(S) YOU HAVE PASSED.

Part VI - PERSONAL HISTORY INFORMATION.

All applicants must complete this section. If you answer YES to any question, you must submit the required

documentation set forth by that question and include a personal statement.

PART VII – EXAM CODING INFORMATION.

All applicants SKIP this section.

Part VIII - CHILD SUPPORT AND TAX INFORMATION.

All applicants must complete this section by law.

Part IX - CERTIFYING STATEMENT.

All applicants must sign and date the application for it to be accepted.

Step II - APPLICATION FEE

 The NON-REFUNDABLE fee must be a check or money order in U.S. currency made payable to IDFPR.

Step III - COMPLETE THE APPLICATION CHECKLIST

 All applicants must complete the checklist and return with the application in order to process the application.

Step IV - MAIL APPLICATION

 Mail the application, fee, application checklist and any supporting documents to the address below.

Illinois Department of Financial and Professional Regulation,

Attn: Division of Professional Regulation, Design/PSS4

P.O. Box 7007

Springﬁ eld, Illinois 62791

Professional Land Surveyor - Page 5

Step V - QUESTIONS

 Before contacting the Department; please review our FAQ’s (http://www.idfpr.illinois.gov/About/FAQ.html)

for answers to most questions. If not addressed in our FAQ’s, please contact the Department at 800.560.6420

or email us at [email protected]

 Please allow four business weeks from applying before making an inquiry concerning its status.

REQUIRED SUPPORTING DOCUMENTS

OFFICIAL TRANSCRIPTS:

Applicants who graduated from a U.S. or Canadian University must submit oﬃ cial conferred degree transcripts

for any degree you wish to claim. Have your University use their respective electronic service to send the

transcript directly to the Department at: [email protected]

Foreign graduates do not need to submit additional copies of their foreign transcripts as they should be included

with the NCEES Credential Evaluation submitted to the Department for Board review of your education.

For licensure: If you are currently enrolled as an Illinois Surveyor Intern, a BS transcript is not required for license

application as you have met the educational requirement. Simply include a copy of your SI certiﬁ cate with your

application.

EXAM CERTIFICATION:

Any exam not passed under the Illinois Jurisdiction requires an oﬃ cial state certiﬁ cation/veriﬁ cation from the state

board where you took the exam through the MyNCEES system to the Illinois PLS Board OR via email to

[email protected] Note: An NCEES score report is not acceptable.

VE-LSR FORM - VERIFICATION OF EMPLOYMENT / EXPERIENCE:

Acceptable experience must be gained under the supervision of a licensed Land Surveyor. The experience

requirement begins AFTER passage of the FS examination.

Complete a separate form for each supervisor/place of employment and have the supervisor complete the form

and email directly to [email protected]

ENDORSEMENT APPLICANTS

LICENSE CERTIFICATION:

An oﬃ cial state certiﬁ cation/veriﬁ cation for proof of active licensure/registration in the current state/territory must

be submitted through the NCEES system to the Illinois PLS Board OR via email from the state board to:

[email protected]

EXPERIENCE REQUIREMENT:

If not submitting an NCEES Record, the Board allows for self-veriﬁ cation of land surveying experience under the

applicant’s own license. Complete the VE-LSR form as your own supervisor.

NCEES RECORD HOLDERS

 Applicants submitting an NCEES Record need only complete page 1 and 4 of the application.

 Applicants submitting an NCEES Record as supplemental documentation to the application are not required to

submit exam or license certiﬁ cations, oﬃ cial transcript(s) or complete the VE-LSR form as long as the

information is included in the record.

 The Board may still require any of the above documents if clariﬁ cation is needed for any reason.

Professional Land Surveyor- Page 6

APPLICATION CHECKLIST

IMPORTANT INFORMATION ONCE LICENSED

 Upon successful passage of the FS, PS and IJ examinations and after your score information has been

received by the Department, you will receive an email from the Department with a link to download

your PLS license.

 All Land Surveyor licenses expire on November 30th of even-numbered years, regardless of issuance date.

 It is your responsibility to update your contact information including email address with the Department to

ensure that you receive all courtesy renewal email reminders and other notiﬁ cations.

 We highly recommend that you review the Code Enforcement Manual as it will provide a sample of what your

Illinois license seal/stamp should look like and other useful information regarding your profession.

You may access the manual here: https://idfpr.illinois.gov/content/dam/soi/en/web/idfpr/forms/dpr/design-code-manual.pdf

APPLICANT NAME: _________________________________ DATE: ________________

All applicants must complete this checklist and return with the completed application. Check only what applies to you.

ALL APPLICANTS TO REVIEW AND CHECK:



A completed original application.

 An application fee, check or money order (payable to IDFPR) in U.S. currency.

 You have requested oﬃ cial transcripts for your conferred Baccalaureate degree and any other education you are

claiming to be sent to the Department. (Not applicable for foreign educated applicants as this should be contained in

your NCEES evaluation).

 You have requested your supervisor(s) to submit a Veriﬁ cation of Experience (VE-LSR) form for experience to be

reviewed. This is required for license applicants not submitting an NCEES Record.

 You have requested a certiﬁ cation from the jurisdiction where the FS Exam was passed (N/A if passed in Illinois)

 You have requested a certiﬁ cation from the jurisdiction where the PS Exam was passed (N/A if passed in Illinois)

 You have requested a certiﬁ cation from the original state of licensure. (For Endorsement applicants)

 You have requested a certiﬁ cation from the current state of active practice. (For Endorsement applicants)

 You have requested an NCEES Record to be sent to the Illinois PLS Board in lieu of transcripts, experience and

certiﬁ cations. Note: The NCEES Record transmittal fee is separate from the license application fee with IDFPR.

FOREIGN EDUCATED APPLICANTS TO REVIEW AND CHECK:



You have requested an NCEES Credentials Evaluation to be sent to the Illinois PLS Board. Required for all

applicants whose BS degree was gained outside the U.S.

 You have requested your TOEFL-iBT examination results to be sent to the Department. (if applicable)

This is the ﬁ rst time I have made application for this

profession in Illinois.

I have previously made application for this profession in

Illinois. However, my previous application expired and I

am now reapplying.

Other:

4. PERMANENT MAILING ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

5. BUSINESS ADDRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

PART I: Application Category Information

4. FEE

C. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION

3. SSN OR ITIN

6. MAIDEN, GIVEN SURNAME, OR ANY NAME(S) UNDER WHICH SUPPORTING

DOCUMENTS WILL BE SUBMITTED. (SEE INSTRUCTIONS #5 ABOVE)

The following materials are required to make Application for Licensure and/

or Examination in Illinois:

1. Four page APPLICATION FOR LICENSURE and /or EXAMINATION.

2. INSTRUCTION SHEET, which gives step by step application

instructions for your profession.

3. REFERENCE SHEET, which gives detailed coding information for

your profession.

4. SUPPORTING DOCUMENTS, forms, and/or any other documentation

you may be required to submit with your application.

5. If the name shown on your supporting documents is diﬀ erent from

that shown on your application, you must submit PROOF OF LEGAL

NAME change - copy of marriage license, divorce decree, aﬃ davit or

court order.

1. PROFESSION NAME

1. NAME LAST FIRST MIDDLE

8. PLACE OF BIRTH CITY STATE/COUNTRY

11. TELEPHONE NUMBER WHERE YOU MAY BE REACHED

PART II: Applicant Identifying Information--You must notify the Department of Financial and Professional Regulation -

Division of Professional Regulation and/or Continental Testing Service in writing, of any address changes after you

ﬁ le this application in order to receive any further information.

IL486-1019 4/24 (LT)

3. LICENSURE METHOD

2. PROFESSION CODE

My application for this profession had previously been denied

in Illinois. I am reapplying since I have fulﬁ lled additional

requirements.

I have previously made application for this profession in

Illinois. However, I am now applying under new statutory

language.

2. TITLE (e.g., M.D., D.D.S., etc.)

Day Year

9. DATE OF BIRTH

Month

B. SEE REFERENCE SHEET, CHART I, OR INSTRUCTIONS PRIOR TO COMPLETING ITEMS 1 THROUGH 4

Carefully follow all steps outlined on the INSTRUCTION SHEET. In addition,

note the following:

A. Type or print legibly with black ink only.

B. FEES ARE NOT REFUNDABLE.

C. Disclosure of your U.S. social security number, if you have one, is mandatory,

in accordance with 5 Illinois Compiled Statutes 100/10-65 to obtain a license.

The social security number may be provided to the Illinois Department of

Public Aid to identify persons who are more than 30 days delinquent in

complying with a child support order, or to the Illinois Department of Revenue

to identify persons who have failed to ﬁ le a tax return, pay tax, penalty or

interest shown in a ﬁ led return, or to pay any ﬁ nal assessment or tax penalty

or interest, as required by any tax Act administered by the Illinois Department

of Revenue, or to other entities for veriﬁ cation of identiﬁ cation.

10. AGE

Female

Male

Work: ( __ __ __ ) __ __ __

__ __ __ __ Home: ( __ __ __ ) __ __ __

__ __ __ __

(Area Code) (Area Code)

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 1 of 4

12.

Additional application forms can be downloaded from the IDFPR Web site at www.idfpr.illinois.gov

7. MOTHER'S MAIDEN NAME

APPLICATION FOR

LICENSURE AND/OR EXAMINATION

IMPORTANT NOTICE: Completion of this form is

necessary for consideration for licensure under 225 of the

Illinois Compiled Statutes. Disclosure of this information

is VOLUNTARY. However, failure to comply may result

in this form not being processed.

Fax: ( __ __ __ ) __ __ __

__ __ __ __ Fax: ( __ __ __ ) __ __ __

__ __ __ __

(Area Code) (Area Code)

REQUIRED

E-MAIL ADDRESS

A. Check the box indicating the appropriate information regarding your application. Military Military Spouse Not Military Decline to Answer

Military service member is deﬁ ned as. “Service member means any person who, at the time of application under this Section, is an active duty member of the United

States Armed Forces or any reserve component of the United States Armed Forces, the Coast Guard, or the National Guard of any state, commonwealth, or territory

of the United States or the District of Columbia or whose active duty service concluded within the preceding 2 years before application.” The following will be

considered proof of you or your spouse’s active military status: DD214, Letter of Service signed by Unit Commanding Oﬃ cer, or Proof of Service document from the

Servicemember's electronic personnel portal. Proof for Spouses: Military Permanent Change of Station Orders with the spouse identiﬁ ed by name; Oﬃ cial

Notiﬁ cation of Change of Assignment with your marriage license, a certiﬁ ed DD1172 verifying marital status, or a letter signed by the commanding oﬃ cer verifying

change of assignment and the name of the military spouse.

Graduated Received

High School? Yes No OR G.E.D.? Yes No

1 2 3 4 5 6 7 8 9 10 11 12

Graduated? Yes No

LOCATION

(City and State or Country)

DATES OF ATTENDANCE

FROM TO

TYPE OF

DEGREE EARNED

6. COLLEGE OR UNIVERSITY NAME

(Undergraduate and Graduate)

Month/Year

DATES OF ATTENDANCE

FROM

LOCATION

(City and State or Country)

Yes No

Month/YearMonth/Year

Did You Complete

Training?

Month/Year

Month Year

4. DATE OF GRADUATION

PART III: Education Information

1. PRELIMINARY EDUCATION (Elementary and High School or G.E.D. Circle number of years completed)

INSTITUTION NAME

1 2 3 4 5 6 7 8

2. NAME OF LAST PRELIMINARY SCHOOL

ATTENDED

3. LAST PRELIMINARY SCHOOL LOCATION

(City and State)

5. COLLEGE OR UNIVERSITY (Circle number of years completed)

7. SPECIALIZED TRAINING (Residency, Professional Training, Vocational Training, Practical or Clinical Training)

IL486-1019

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 2 of 4

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

PART IV: Record of Licensure Information

IL486-1019

(If additional space is needed, attach a separate sheet.)

PROFESSION NAMESTATE

State of Current Licensure where you

most recently have been practicing.

Other States of Licensure

NAME OF EXAMINATION

(If additional space is needed, attach a separate sheet.)

PART V: Record of Examination

DATE OF

ISSUANCE

LICENSE NUMBER

LICENSE STATUS

(Active, Lapsed, etc.)

STATE

MONTH/YEAR EXAM RESULTS

(Passed, Failed, Absent)

If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making

application, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN.

Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.

If you have ever been licensed to practice the profession for which you are now making application, or held a related license, complete

the information requested below. If you have ever held a temporary, trainee or apprenticeship license, or a permit, it must be listed here

also. In addition, the INSTRUCTION SHEET enclosed with this Application package may instruct you to have Certiﬁ cation(s) of Licen-

sure in other state(s) prepared and submitted in support of your application (contact other state(s) regarding possible fee). You must

also list all other licenses held in Illinois, however, certiﬁ cation of licensure from Illinois is not required. Failure to disclose all licenses

held may result in denial of your application or other appropriate action.

State of Original Licensure

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 3 of 4

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

PART VI: Personal History Information (This part must be completed by all applicants)

NOYES

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me

in connection therewith, and to the best of my knowledge, they are true, correct, and complete. I UNDERSTAND THAT

FEES ARE NOT REFUNDABLE.

Signature of Applicant Date

PART IX: Certifying Statement

IL486-1019

APPLICATION FOR LICENSURE AND/OR EXAMINATION - Page 4 of 4

PART VIII: Child Support, Tax Information and Workers' Compensation (Every applicant is required by law to

respond to the following questions)

PART VII: Examination Coding Information (This part is for examination applicants only)

Refer to the REFERENCE SHEET enclosed with this application package and complete the following:

a) CHART II - Select examination(s) you desire

and enter Test Codes

b) CHART III - Select the examination site you desire and enter Test Center Code:

c) CHART IV - Find your School of Graduation and enter school code:

d) Record the number of times you have taken this exam in Illinois or any other state:

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________

1. In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's

Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying

with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to

contempt of court.

Are you more than 30 days delinquent in complying with a child support order? Yes No

(NOTE: If you are not subject to a child support order, answer "no.")

2. In accordance with 20 ILCS 2105-15(g), "The Department shall deny any license application or renewal authorized under any licensing Act

administered by the Department to any person who has failed to ﬁ le a return, or to pay the tax, penalty, or interest shown in a ﬁ led return, or to

pay any ﬁ nal assessment of tax, penalty, or interest, as required by any tax Act administered by the Illinois Department of Revenue, until such

time as the requirement of any such tax Act is satisﬁ ed."

Are you delinquent in the ﬁ ling of state taxes? Yes No

3. In accordance with 20 ILCS 2105/2105-15(g-5), “The Department shall refuse the issuance or renewal of a license to, or suspend or revoke

the license of, any individual, corporation, partnership, or other business entity that has been found by the Illinois Workers' Compensation

Commission or the Department of Insurance to have failed to secure workers' compensation obligations, or pay in full a ﬁ ne or penalty imposed

due to a failure to secure workers' compensation obligations.”

Are you delinquent in complying with workers’ compensation obligations? Yes No

1. Have you been convicted of or pled guilty or nolo contendere to any criminal oﬀ ense in any state or in federal court? Please do not give

details on minor traﬃ c charges, but do include information relating to Driving While Intoxicated (DWI) charges. If yes, attach a personal

statement describing the circumstances of the conviction and certiﬁ ed copies of court records of your conviction including the nature of

the oﬀ ense, date of discharge, and a statement from the probation or parole oﬃ ce. In general, a criminal conviction by itself does not

usually result in denial of licensure.

2. Have you been convicted of a felony? In general, a felony conviction by itself does not usually result in denial of licensure.

3. If yes, have you been issued a Certiﬁ cate of Relief from Disabilities by the Prisoner Review Board? If yes, attach a copy of the certiﬁ cate.

4. Do you now have any disease or condition that presently limits your ability to perform the essential functions of your profession, including

any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition; (2)

alcohol or other substance abuse; (3) physical disease or condition? If yes, attach a detailed statement, including an explanation whether

or not you are currently under treatment.

5. Have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit

disciplined in any way by any licensing authority in Illinois or elsewhere? If yes, attach a detailed explanation.

6. Have you ever been discharged other than honorably from the armed service or from a city, county, state or federal position? If yes, attach

a detailed explanation.

APPLICANT INFORMATION:

IL486-1337 01/24 (LY)

SUPPORTING DOCUMENT

VERIFICATION OF

EMPLOYMENT/EXPERIENCE

IMPORTANT NOTICE: Completion of this form is

necessary for consideration for licensure under 225 ILCS

340/1 et. seq. (Illinois Compiled Statutes). Disclosure

of this information is VOLUNTARY. However, failure to

comply may result in this form not being processed.

A. SUPERVISOR NAME

B. EMPLOYER'S NAME (AT TIME OF SUPERVISON)

1. NAME LAST FIRST MIDDLE

2. LAST FOUR DIGITS OF YOUR SSN OR ITIN

DEPARTMENT USE ONLY

REQUIREMENTS AND INSTRUCTIONS:

C. DATES OF EMPLOYMENT (Use exact dates, not "present")

A. TYPE OF EMPLOYMENT

B. TOTAL TIME EMPLOYED

Full-time Part-time

____Years ____Months

From To

Applicants who do not submit experience as part of an NCEES Record must complete this form. For experience to be accepted, the

supervisor must be licensed as a Professional Land Surveyor pursuant to Section 5 of the PLS Act; who is in direct control and

supervision of the applicant.

Applicant: Complete the top portion of the form then forward to your supervisor to complete the remainder of it. Applicants applying for

Endorsement without an NCEES Record may self-verify their experience as the supervisor from the date of initial licensure.

Supervisor: Complete the remainder of the form and email it directly to the Department at the address below in order for it to be

associated with the applicant’s application for review by the Board.

Email to: [email protected]

SUPERVISOR INFORMATION:

EMPLOYMENT / EXPERIENCE INFORMATION:

1. APPLICANT EMPLOYMENT INFORMATION DURING YOUR SUPERVISION.

2. RESPONSIBLE CHARGE REQUIREMENT.

Was the applicant in responsible charge of the land surveying activities with responsibility for successful accomplishment of the work,

SUBJECT TO THE OVERALL SUPERVISION OF A LICENSED PROFESSIONAL LAND SURVEYOR, including but not limited to, making

decisions on questions pertaining to the establishment or reestablishment of boundary lines, determining the position of any monument,

etc.? NO YES

3. If you answered YES to the above, please indicate the number of months in Responsible Charge below.

Number of Months in Responsible Charge under your supervision: _________________

(If no experience was in Responsible Charge, please indicate with a zero)

VE-LSR - Professional Reference - Page 1 of 2

VE - LSR

C. SUPERVISOR LICENSE INFORMATION

APPLICABLE STATE(S) MO/YR INITIALLY LICENSE

OF LICENSURE LICENSED NUMBER

E. SUPERVISOR CONTACT INFORMATION

D. SUPERVISOR'S WORK ADDRESS (AT TIME OF SUPERVISON)

STREET, CITY, STATE, ZIP CODE

Phone ( )

Email ____________________________________________

4. IN YOUR PROFESSIONAL OPINION, IS THERE ANYTHING THAT WOULD CAUSE YOU TO BELIEVE THE APPLICANT

SHOULD NOT BE LICENSED IN ILLINOIS AS A PROFESSIONAL LAND SURVEYOR AT THIS TIME?

NO YES (explain below if yes)

IL486-1337 (LY)

I CERTIFY THAT I WAS LICENSED OR LEGALLY PRACTICING IN ALL APPLICABLE JURISDICTIONS FOR THE PROJECTS

LISTED ON THIS EXPERIENCE FORM. I UNDERSTAND THAT IF I AM NOT, THE EXPERIENCE SHALL NOT BE ACCEPTED.

I do hereby declare that this applicant was employed by me or worked under my personal supervision for the time period listed and

that the information I have reported herein is true and correct to the best of my knowledge.

Date Signature Primary Jurisdiction Seal

6. DESCRIPTION OF LAND SURVEYING PROJECTS.

Describe in detail, the types of land surveying projects on which the applicant worked under your supervisor.

Acceptable experience shall be within the deﬁ nition of the practice as set forth in Section 5 of the Act and shall require the application

of technical knowledge and land surveying principles.

Please keep in mind when you are completing this form that an applicant’s acceptable experience is evaluated from information

furnished entirely from you. For this reason, it is important that the Board be able to make a clear determination on the applicant’s role

for each project listed and the type of work they performed under your supervision.

Project descriptions should be listed in the below format. Attach additional sheets if necessary.

1) Name, location and type of project

2) Applicant role in the design of the project

3) Name of Surveyor of Record for the project

5. DID THE APPLICANT, UNDER YOUR OVERALL SUPERVISION, ENGAGE IN THE FOLLOWING SURVEYING ACTIVITIES 25% TO 50% OF

TIME:

a) ﬁ eld procedures to perform boundary surveys of existing or proposed tracts of land;

b) ﬁ eld procedures to locate or re-establish section corners that are part of the public land survey system;

c) ﬁ eld procedures to perform surveys for subdivisions and condominiums.

DID THE APPLICANT, UNDER YOUR OVERALL SUPERVISION, ENGAGE IN THE FOLLOWING SURVEYING ACTIVITIES THE REMAINING

PERCENT OF TIME:

a) research of records to obtain data to perform boundary surveys or obtain other required data;

b) calculations and analyses of data to determine locations, dimensions and area of existing or proposed tracts of land;

c) calculations and analyses of data to determine position of section corners or locations, dimensions or areas of aliquot

parts of sections, all in the public land survey system;

d) preparation of legal descriptions;

e) preparation of plats of surveys for existing or proposed tracts of land;

f) preparation of plats of subdivisions and/or plats of condominiums;

g) preparation of section corner monument records;

h) ﬁ eld procedures to perform topographic surveys;

i) preparation of topographic plats of surveys.

j) staking the alignments or elevation of proposed improvements.

Yes

SUPERVISOR CERTIFICATION:

VE-LSR - Professional Reference - Page 2 of 2

NAME (Last, First, MI): ___________________________________________ SSN OR ITIN: _____________________ Profession: ____________________