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					Division of Registrations                                                                                                  Reinstatement Application
Office of Licensing–Professional Engineers                                                               For licenses expired MORE than two years
(303) 894-7800 / FAX (303) 894-7693                                                                                    PROFESSIONAL ENGINEER                                                                                                        Fee: $65
To reinstate your expired Professional Engineer license:
 Complete this form, attaching any required supporting documentation. For a name change, provide a copy of the legal
    document verifying the change (i.e., marriage license, divorce decree, or court order).
 Pay the reinstatement fee. Fees may be paid by a check or money order drawn in U.S. dollars and made payable to
    State of Colorado. All fees are non-refundable and subject to change every July 1.
 Return the completed form, any required documentation, and the reinstatement fee to: Division of Registrations,
    Office of Licensing, 1560 Broadway, Suite 1350, Denver, Colorado, 80202.
Please read the detailed instructions before completing this application and forms.
The application and all accompanying forms (except the Affidavit of Eligibility) must be typed. Handwritten
applications will be rejected.

                                 The content of this application must not be changed. If the content is changed,
                   the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law.

                                                         PART 1—APPLICANT INFORMATION
Colorado Professional Engineer License Number:

Original Date of Licensure:                                     Date License Expired:

Name (Last/First/Middle/Suffix):

Previous Name(s):

Social Security Number*:                                        Date of Birth (mm/dd/yyyy):                                     Gender:          Male        Female

Place of Birth:

Preferred Mailing Address:
    (PO Box, City, State, Zip)
This is a        Home      Business

Daytime Telephone Number:                                              E-mail Address:

Company Name:                                                                                 Present Position Title:

Company Address:
    (PO Box, City, State, Zip)

                                                        PART 2—REFERENCE INFORMATION
                             I have included a sealed and signed envelope containing a completed
                            Engineering Experience Verification Form from the following individuals:

* Social Security Number Disclosure: Section 24-34-107(1) of the Colorado Revised Statutes requires that every application by an individual for a license issued
pursuant to the authority set forth in title 12, C.R.S., by the Department of Regulatory Agencies, shall require the applicant's social security number. Disclosure of
your social security number is mandatory for purposes of establishing, modifying, or enforcing child support under § 14-14-113 and § 26-13-126, C.R.S.; and
locating an individual who is under an obligation to pay child support as required by § 26-13-107(3)(a)(I)(A), C.R.S. Failure to provide your social security number
for these mandatory purposes will result in the denial of your licensure application. Disclosure of your social security number is voluntary for disclosure to other
state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional
regulation for identification purposes only. Your social security number will not be released for any other purpose not provided for by law.

PE Reinstatement > 2 Years                                                   Page 1 of 2                                                                        8/2010
                                                                          APPLICANT NAME:

                                               PART 3—LICENSE INFORMATION

Why did you let your license expire?

Why would you like to reinstate your license at this time?

Since the date your license expired, have you offered to practice and/or practiced engineering                      YES        NO
in Colorado such that you, or your employer, represented yourself as being licensed through
promotional material, proposals, reports, etc., or you signed and/or sealed documents,
reports, and/or drawings?
        If YES, provide an explanation on an attached sheet.
Are there any pending complaints against you in any other jurisdictions?                                            YES         NO

List each jurisdiction in which you are or have been licensed as a Professional Engineer (if necessary, attach an additional
sheet in the same format).
                                                                              Year            Disciplinary action         Is this license
Type of license                State/Country            License Number        issued          against license?            current/active?
                                                                                                     YES      NO             YES      NO
                                                                                                     YES      NO             YES      NO
                                                                                                     YES      NO             YES      NO

                                               PART 4—SCREENING QUESTIONS
        If your answer is YES to any of the following questions, you must provide a letter of explanation that includes
                    date of offense, type of offense, penalty, and whether all requirements were satisfied.

Since the date your license expired:
1. Have you had disciplinary action taken against you by another jurisdiction?                                       YES           NO

2. Have you been arrested, charged, convicted and/or pled guilty to a felony under the laws of any                   YES           NO
   jurisdiction in the United States?

3. Have you been convicted of a misdemeanor drug or alcohol offense under the laws of any                            YES           NO
   jurisdiction in the United States?

4. Have you been convicted of misdemeanor fraud, misrepresentation or deceit offense under the                       YES           NO
   laws of any jurisdiction in the United States?

I state under penalty of perjury in the second degree, as defined in CRS 18-8-503, that the information contained
in this application is true and correct to the best of my knowledge. In accordance with CRS 18-8-501(2)(a)(I), false
statements made herein are punishable by law and may constitute violation of the practice act.

Applicant’s Signature                                                                  Date

PE Reinstatement > 2 Years                                Page 2 of 2                                                              8/2010

APPLICANT NAME:                                                                                                Page _       _ of
                                                                                                               _        _ pages

                                                                 1.   Technician Experience
Dates of Work                      List                          2.   Design Experience                      Supervisor Name,
      In                        Your Title,                      3.   Project Engineering                     Licensure Status,
Chronological               Company Name and                     4.   Engineering Management                 Title and Company
    Order             Your Responsibilities for All Jobs         5.   Other
                        Since Your License Expired                    See Engineering Experience Summary
   (Do Not                                                                      Form Instructions
   Overlap)     ACCOUNT FOR ALL GAPS IN EMPLOYMENT                    Enter each column as a percentage of
                 (e.g. school, unemployed, traveling, etc.)                  experience for that position.
                                                                      All five columns must total 100% for
                                                                                   each position
From:    To:                                                       (1)       (2)      (3)      (4)     (5)
mo/yr   mo/yr

                If more than one page is needed, you may copy for a total of no more than three (3) pages.

                     APPLICANT: Complete this page 1 and insert your name at the top of page 2.



 Company Name:
 State/Zip Code:

 E-mail Address:

 Daytime Phone:                        Extension:

                                                                          1.   Technician Experience
Dates of Work        List Title, Company Name & Responsibilities          2.   Design Experience                           Name of
                                                                          3.   Project Engineering                        Reference
                                                                          4.   Engineering Management                      Verifying
                   Insert the SAME description of this engagement
                                                                          5.   Other
                   from the Engineering Experience Summary Form                                                          Experience,
                                                                               All five columns must total 100% for   Licensure Status,
                                                                                            each position             Title & Company
From:     To:                                                              (1)        (2)      (3)      (4)     (5)
mo/yr    mo/yr

                     You may continue the experience description on a second page if necessary.

APPLICANT: Provide this completed page 1, page 2 with your name at the top, and a copy of the engineering
experience definitions to your reference to fill out. Completed Pages 1 and 2 must remain in the sealed and signed
envelope as returned to you by your reference and included with your application.

                                          Engineering Experience Verification Form – Page 1 of 2
                                                                                      Applicant Name:

REFERENCE: Please review the Applicant’s job description on page 1 and answer the questions below.
 Please do not complete this form in the Applicant’s presence – the information you provide is confidential.
 After completing the page below, place both pages 1 and 2 of this form in a business size envelope.
 Seal the envelope and sign your name across the flap on the back of the envelope.
 Return the sealed envelope directly to the applicant – do not send it to the Board office.
 Note that the Applicant will only get credit for this experience if this form is completely filled out and it is received
   from the Applicant in the original, sealed envelope that you have personally signed on the back.

 1.   Do you concur with the description of experience, including dates, duties, and the stated percentage of
      time in the types of engineering experience, on page 1?                                                        Yes  No
 2.   My business or profession is:
 3.   My professional relationship to the Applicant is/has been:
       Employer  Supervisor  Co-Worker  Associate  Reviewed Work  Other:
 4.   Are you related to this Applicant by blood, marriage or adoption?  Yes*  No
 5.   I am a licensed engineer in the state(s) of:                                             License Number:
 6.   I have known the Applicant for:                        (years/months) From:                          To:
 7.   My appraisal as to how this Applicant has performed regarding skills, knowledge and responsibility appropriate for a
      Professional Engineer is:        Satisfactory  Not Satisfactory  Don’t Know
 8.   Do you consider the Applicant technically qualified to be a PE?                              Yes  No*
 9.   I have personally seen and reviewed the Applicant’s plans, calculations and/or reports.      Yes  No
10.   My appraisal of the Applicant’s engineering performance is:
                 FACTOR                   SATISFACTORY              UNSATISFACTORY            DON’T KNOW
      Technical Competence                                                                      
      Engineering Judgment                                                                      
      Professional Integrity/Ethics                                                             
      Project Communications                                                                    
      Independent Decision Making                                                               
      Coordination of Project Staff                                                             
      Code/Regulatory Knowledge                                                                 
      Responsible Charge Capability                                                             

* REMARKS: Explanation to starred responses above and/or comments about the Applicant’s qualifications

In accordance with Sections 18-8-503 and 18-8-501 (2) (a) (I), CRS, false statements made herein are punishable by law. I state
under penalty of perjury as defined in Section 18-8-503, CRS, that the information contained on this form is true and correct to the
best of my knowledge.

Reference Name: (print)                                                  Reference Signature:
Reference Title:                                                         Date:

Reference Address:                                                                                   Day Phone:

Name of Employer:                                                                                    Fax Number:
E-mail Address:

                                            Engineering Experience Verification Form – Page 2 of 2

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