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Request for Inactive Status

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					                                                                  Engineers/Land Surveyors/Photogrammetrists/Water Right Examiners

                                    BOARD OF EXAMINERS                           Request for Inactive Status
                                    FOR ENGINEERING &
                                    LAND SURVEYING
                                                                                    Instructions | Page 1 of 1
670 Hawthorne Avenue, SE                                                                                                  tel. 503.362.2666
Suite 220                                                                                                       email: osbeels@osbeels.org
Salem, Oregon 97301                                                                                          Web: www.oregon.gov/osbeels

                                              Request for Inactive Status
The following instructions are provided to assist in
completing the Request for Inactive Status form.                         PLEASE NOTE: It is the registrant’s responsibility
                                                                         to submit all documentation required. Failure to
PLEASE READ the applicable Oregon Revised Statutes and                   properly complete the form may result in a delay of
the Oregon Administrative Rules. To locate the ORSs and                  processing.
the OARs, visit our Web site at www.oregon.gov/osbeels.
Click on the “Revised Statutes” link for the ORSs. Click on
the “Administrative Rules” link for the OARs.

Who Should Fill Out the Request for Inactive Form?
          Registrants who want to request to place their registration(s) as a professional engineer (PE), professional land
          surveyor (PLS), registered professional photogrammetrist (RPP), and/or certification as a certified water right
          examiner (CWRE) into the inactive status due to a debilitating mental or physical illness, injury or disease as
          provided in OAR 820-010-0520.
          If requesting inactive status on behalf of a registrant, send a certified copy or legal document(s) proving your authority, such
          as current power of attorney, guardianship, etc.
          Certified as a CWRE?
          Registrants who are placed into the inactive status and also hold a certification as a CWRE, must place their
          CWRE certificate into the inactive status.
          See the following ORS and OARs for detailed information (CWRE): ORS 537.798, OAR 690-014-0050, OAR 820-
          010-0235, and OAR 820-010-0520.
Inactive Fees
          See the following OARs for detailed information: OAR 820-010-0300, OAR 820-010-0305, and OAR 820-010-0505.

          $90.00 – PE Biennial Inactive Renewal                      $90.00 – RPP Biennial Inactive Renewal
          $90.00 – PLS Biennial Inactive Renewal                     $20.00 – CWRE Biennial Inactive Renewal
How Requests are Processed
          Requests will be processed according to the date received by the OSBEELS office.


GENERAL INSTRUCTIONS
Step 1:   Complete the form(s) and sign it in the presence of a notary public.
Step 2:   Gather completed form(s) and documents and put together in a single package for mailing.
Step 3:   Send form(s) to the Oregon State Board of Examiners for Engineering and Land Surveying (OSBEELS):
          OSBEELS
          670 Hawthorne Avenue, SE
          Suite 220
          Salem, OR 97301
Step 4:   If correspondence has not been received from the OSBEELS within 60 days of submittal, please contact
          us.

Oregon State Board of Examiners for Engineering and Land Surveying                                                tel. 503.362.2666
form INACTIVE, updated 11/19/2009                                                                      email: osbeels@osbeels.org
                                                                             Office Use Only - Date Received:               Office Use Only -
                                                                                                                            Date Entered/Paid:
                                        BOARD OF EXAMINERS
                                        FOR ENGINEERING &
                                        LAND SURVEYING
 670 Hawthorne Avenue, SE                             tel. 503.362.2666
 Suite 220                                  email: osbeels@osbeels.org
 Salem, Oregon 97301                     Web: www.oregon.gov/osbeels

 Office Use Only - ID #:

Request for Inactive Status: PE/PLS/RPP
It is the registrant’s responsibility for reviewing the requirements when requesting to place a registration as a PE, PLS, and/or RPP in the inactive
status. Please read the applicable Oregon Revised Statute(s) (ORSs) and the Oregon Administrative Rule(s) (OARs) before applying for inactive
registration.

   Registrant Contact Information
   First name (personal name)                   Middle name or initial                  Last name (family name)


   Home/Personal phone #                        Home email address                      Birth date (Mo/Day/Yr)


   Mailing address (include any apartment numbers)


   City                                         State or Province                       Zip/Postal code                   Country


   Registered to practice as:                                                Registration number(s):
   o PE        o PLS    o RPP
   I request to place my registration(s) to practice into inactive status.

   I understand that by placing my registration(s) into the inactive status, as defined in the Oregon Administrative Rule
   (OAR) 820-010-0520, I am no longer authorized to engage in the professional practice of engineering, land surveying, and/or
   photogrammetric mapping as defined in the Oregon Revised Statute (ORS), Chapter 672.

   I understand that I may return to the active status only upon application to the Board, by paying a reinstatement fee and
   biennial renewal fee required by the OAR 820-010-0305 and completing 15 PDH units per year for each year (or part of a year)
   inactive, to a maxium of 30 PDH units.
   Signature                                                                                                Date (Mo/Day/Yr)



Notary Use

   Witness
   State of:                                                                                Place Official Seal below


   County of:


   Date (Mo/Day/Yr):


   Signature


   Notary Public - State of:



Oregon State Board of Examiners for Engineering and Land Surveying                                                           tel. 503.362.2666
form INACTIVE, updated 11/19/2009                                                                                 email: osbeels@osbeels.org
                                                                      Engineers/Land Surveyors/Photogrammetrists/Water Right Examiners

                                       BOARD OF EXAMINERS                               Request for Inactive Status
                                       FOR ENGINEERING &
                                       LAND SURVEYING
                                                                                                       Page 2 of 2


  Please check the applicable boxes and enclose the appropriate amount for each request
  o PE Biennial Inactive Renewal - $90.00                                   o PLS Biennial Inactive Renewal - $90.00

  o RPP Biennial Inactive Renewal - $90.00                                  Include documentation prepared by a licensed physician (see OAR
                                                                            820-010-0520).


  Select payment method (choose one)
  o Check or Money Order (payable to the OSBEELS) o Cash                              Amount Enclosed:


  o Debit or Credit Card (Visa, Mastercard, Discover, or AmEx)                        Total Charge to Card:


  Card Number                                                  Exp. Date              Security Code*         Billing Zip/Postal Code



  Signature (serves as payment authorization if paying by debit or credit card)                              Signature Date (Mo/Day/Yr)




 * Debit or Credit Card Security Codes
   If submitting a payment to the OSBEELS for fees by debit or credit card, please provide the security code. These codes are a security feature that
   appears on the back of most Visa, MasterCard, and Discover cards, and on the front of American Express cards. This code is a three or four-digit
   number which provides a cryptographic check on the information embossed on the card.

   American Express Card Users: Look for the 4-digit code printed on the front of the card just above and to the right of the main card number. This
   4-digit code is the card security code. Visa, MasterCard, and Discover Card Users: Flip the card over and look at the signature box. A special
   3-digit code will be located in the signature box. This 3-digit code is the card security code.




Oregon State Board of Examiners for Engineering and Land Surveying                                                          tel. 503.362.2666
form INACTIVE, updated 11/19/2009                                                                                email: osbeels@osbeels.org
                                                                             Office Use Only - Date Received:                Office Use Only -
                                                                                                                             Date Entered/Paid:
                                        BOARD OF EXAMINERS
                                        FOR ENGINEERING &
                                        LAND SURVEYING
 670 Hawthorne Avenue, SE                             tel. 503.362.2666
 Suite 220                                  email: osbeels@osbeels.org
 Salem, Oregon 97301                     Web: www.oregon.gov/osbeels

 Office Use Only - ID #:

Request for Inactive Status: CWRE
It is the registrant’s responsibility for reviewing the requirements when requesting to place a certification as a CWRE in the inactive status. Please
read the applicable Oregon Revised Statute(s) (ORSs) and the Oregon Administrative Rule(s) (OARs) before applying for inactive registration.

   Registrant Contact Information
   First name (personal name)                   Middle name or initial                  Last name (family name)


   Home/Personal phone #                        Home email address                      Birth date (Mo/Day/Yr)


   Mailing address (include any apartment numbers or suite numbers)


   City                                         State or Province                       Zip/Postal code                   Country


   Certified to practice as:                                                 Certification number:
   o CWRE

   I request to place my certification to practice into inactive status.

   I am no longer authorized to engage in the professional activities of a certified water right examiner as defined in the Oregon
   Revised Statute (ORS), Chapter 537 and the Oregon Administrative Rules (OAR), Chapter 820 and Chapter 690.

   I understand that I may return to the active status only upon application to the Board, by paying a reinstatement fee and
   biennial renewal fee required by the OAR 820-010-0305 and returning a certificate of registration as a professional engineer,
   professional land surveyor, and/or registration as a geologist to the active status.
   Signature                                                                                                 Date (Mo/Day/Yr)



Notary Use

   Witness
   State of:                                                                                 Place Official Seal below


   County of:


   Date (Mo/Day/Yr):


   Signature


   Notary Public - State of:




Oregon State Board of Examiners for Engineering and Land Surveying                                                           tel. 503.362.2666
form INACTIVE, updated 11/19/2009                                                                                 email: osbeels@osbeels.org
                                                                      Engineers/Land Surveyors/Photogrammetrists/Water Right Examiners

                                       BOARD OF EXAMINERS                               Request for Inactive Status
                                       FOR ENGINEERING &
                                       LAND SURVEYING
                                                                                                       Page 2 of 2


  Please check the applicable box and enclose the appropriate amount
  o CWRE Biennial Inactive Renewal - $20.00                                 Include documentation prepared by a licensed physician (see OAR
                                                                            820-010-0520).

  Select payment method (choose one)
  o Check or Money Order (payable to the OSBEELS) o Cash                              Amount Enclosed:


  o Debit or Credit Card (Visa, Mastercard, Discover, or AmEx)                        Total Charge to Card:


  Card Number                                                  Exp. Date              Security Code*         Billing Zip/Postal Code



  Signature (serves as payment authorization if paying by debit or credit card)                              Signature Date (Mo/Day/Yr)




 * Debit or Credit Card Security Codes
   If submitting a payment to the OSBEELS for fees by debit or credit card, please provide the security code. These codes are a security feature that
   appears on the back of most Visa, MasterCard, and Discover cards, and on the front of American Express cards. This code is a three or four-digit
   number which provides a cryptographic check on the information embossed on the card.

   American Express Card Users: Look for the 4-digit code printed on the front of the card just above and to the right of the main card number. This
   4-digit code is the card security code. Visa, MasterCard, and Discover Card Users: Flip the card over and look at the signature box. A special
   3-digit code will be located in the signature box. This 3-digit code is the card security code.




Oregon State Board of Examiners for Engineering and Land Surveying                                                          tel. 503.362.2666
form INACTIVE, updated 11/19/2009                                                                                email: osbeels@osbeels.org

				
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