Free 49990.FH11 - Indiana

APPLICATION FOR APPROVAL OF LAND SURVEYOR CONTINUING EDUCATION PROVIDER
State Form 49990 (R / 4-07)

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STATE BOARD OF REGISTRATION FOR LAND SURVEYORS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3022 E-mail: [email protected]

INSTRUCTIONS:

1. Attach descriptive course content outline for each course, pursuant 865 IAC 1-13-6 or 865 IAC 1-14-7, clearly expressing course objectives and indicating number of hours for each course. 2. Attach a professional biography of each instructor that indicates compliance with 865 IAC 1-14-9. 3. Attach a student evaluation form.

Name of provider Address (number and street, city, state, and ZIP code) Telephone number E-mail address

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Name of contact person Address (number and street, city, state, and ZIP code) Telephone number E-mail address

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COURSES COURSE NAME HOURS

(Continued on the reverse side.)

INSTRUCTORS NAME OF INSTRUCTOR NAME OF INSTRUCTOR

Do you agree to provide a certificate of course completion to every participant that completes your course(s) pursuant to 865 IAC 1-14-13? Have you read and understand the statutes and rules regarding continuing education that were provided with this application?

Yes Yes

No No

FOR OFFICE USE ONLY Approved Tabled Reason:

Denied

Reason:

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