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This form must be submitted directly by the endorser. The Office of the Professions will not accept this form if submitted by the applicant.
  • Sections I and II: Complete these sections, in parts A and B of Section II, list your experience in a comprehensive, detailed, and explicit manner. Be sure to sign and date the attestation at the end of Section II before giving the entire form to the licensed land surveyor who will verify your experience. Descriptions must be specific about your personal contributions to land surveying projects to which you were assigned. Avoid terms like "...participated in...," "...involved with...," or similar generalities. State your exact duties. Your personal surveying work must be described in reasonable detail. Regardless of the total time claimed on a single sheet, you must break the total time down in segments, each of which describes one kind of work you have performed. For each segment, provide a detailed description of your personal activities that would allow the State Board to properly evaluate that work. Remember to indicate in the time column the total time you spent on each specific kind of work. Attach additional sheets if necessary.
  • Section III: The licensed land surveyor who will verify your experience must complete this section, sign the attestation endorsing your professional experience before returning all pages of this form directly to the Office of the Professions at the address at the end of the form. The endorser's signature on Form 4A must be notarized by a Notary Public.

A separate Form 4A must be submitted for each instance of professional experience you list on the Report of Professional Experience form (Form 4). Your application will not be reviewed by the Board until a Form 4A for every employer listed has been received.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

  • OP can independently verify that the documentation is received directly from the supervisor
  • The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
  • Any experience documentation submissions should be made electronically to*.
*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.