Free 50666.FH11 - Indiana

INDIVIDUAL REQUEST FOR LAND SURVEYOR CONTINUING EDUCATION COURSE APPROVAL
State Form 50666 (R / 4-07)

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:

Please attach the following: 1. Course outline or description 2. Name, address, and professional biography of the instructor 3. Course completion certificate pursuant to 865 IAC 1-14-13

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

License number

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COURSE(S) NAME OF COURSE COURSE LOCATION DATE OF COURSE NUMBER (month, day, year) OF HOURS BOARD ACTION

COURSE PROVIDER
Name of course provider Address (number and street, city, state, and ZIP code) Telephone number

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CERTIFIED STATEMENT

I hereby certify that I have completed the entire course(s) indicated above and request approval of such courses to comply with my continuing education requirement pursuant to 865 IAC 1-13 and 865 IAC 1-14.
Signature of registered land surveyor Date (month, day, year)

FOR OFFICE USE ONLY
Board comments: (continue on reverse side if needed)

Board signature

Date (month, day, year)