LSP Application Form

LSP APPLICATION FORM

If you have applied previously, please enter your previous application number here:

[NOTE: If you applied previously, and you took but did not pass the Board’s licensing exam, do not use this Application Form. Call 617-556-1091 and ask for the “Limited” Application Form.]

FORM 1

APPLICANT INFORMATION

Will the Board receive information about you under a different name?

If your answer is “Yes,” fill in that name below:

Mailing Address: When corresponding with you about your Application, the Board will use the address you provide below. Please indicate whether this is your home or business address by placing an “X” in the appropriate box.

Address:

E-Mail/Internet Address:

Telephone Number(s):

Applicant’s Selection of Standard or Alternate Track and Qualifying Degree:

Based on the Minimum Education Requirements in Section 3.02(1) of the regulations, indicate under which “Track” you want to be considered for licensure and provide the requested information about your qualifying educational degree:

CHECK ONLY ONE:

FORM 2

RELEVANT PROFESSIONAL EXPERIENCE (“RPE”)

POSITION DESCRIPTIONS

Position Description (Do Not Just Name; Give a Brief Description):

Was position less than an average of 20 hours/week?

If yes, average hours/week:

Field(s) of Expertise for this position:

Answer the following questions in the spaces provided:

a. Explain your duties and responsibilities in this Position and describe how these duties and responsibilities involved work related to site assessments, risk characterizations, and/or remediation activities at contaminated sites. Describe the level of your duties and responsibilities within this Position at your company or organization.

FORM 3

RELEVANT PROFESSIONAL EXPERIENCE (“RPE”)

PROJECT DESCRIPTIONS

This Project involved:

Did subsurface investigations occur during this Project?

Project Information:

a. Describe how you applied technical knowledge and skill in one or more of your fields of expertise to this Project, and describe how you evaluated and selected the scientific or technical methods used.

FORM 4

RELEVANT PROFESSIONAL EXPERIENCE (“RPE”)

SUMMARY OF POSITIONS

RELEVANT PROFESSIONAL EXPERIENCE claimed:

FORM 5

OPTIONAL STATEMENT OF QUALIFICATIONS

Applicant’s Name:

In this space, in 250 words or less, you may provide additional information in support of your claim that you meet the requirements for Relevant Professional Experience (“RPE”).

FORM 6

TOTAL PROFESSIONAL EXPERIENCE (“TPE”)

POSITION DESCRIPTIONS

Was Position less than an average of 20 hours/week?

If yes, average hours/week:

a. Describe the environmental, scientific, and engineering fields that your work involved.

b. Describe how your work involved the application of scientific or engineering principles.

c. Describe the nature of your conclusions you reached and describe how those conclusions formed the basis for reports, studies, or other documents.

FORM 7

SUMMARY OF TOTAL PROFESSIONAL EXPERIENCE (“TPE”) CLAIMED

Applicant’s Name:

FORM 8

SUMMARY OF PROFESSIONAL REFERENCES

The Board requires a total of four (4) professional references. Additional references will not be accepted.

Reference Handling Instructions:

Step 1: Download and save the LSP Professional Reference Form from the Applications section of the Board’s website.

Step 2: E-mail a copy of this Reference Form to each of your References.

Step 3: In your separate e-mails to them, instruct each of your Reference to carefully read and follow the Instructions on the second page of the LSP Professional Reference Form.

Step 4: When you receive the envelopes containing the 4 completed Reference Forms, do not open the sealed return envelopes.

Please note the following:

1) The Board will reject an Application when it is evident that one or more Reference envelopes have been opened or otherwise tampered with.

2) Failure to provide up-to-date telephone numbers for each of your References may delay the processing of your Application.