NOTICE OF VOLUNTARY LICENSE SURRENDER IN LIEU OF DISCIPLINE
Name of Licensee:
License No.:
EFFECTIVE this _______ day of ______________________, 20__, I hereby agree to voluntarily surrender my license as a professional engineer/professional land surveyor for the State of Idaho, identified above, in lieu of disciplinary action effective this date. I have enclosed with this Notice any current wallet card and the wall certificate and will hand-deliver them or send them by first class mail to the Idaho Board of Professional Engineers and Professional Land Surveyors, Attn: Keith Simila, P.E., Executive Director, 1510 E. Watertower Street, Suite 110, Meridian, Idaho 83642-7993.
I agree to not offer or perform any activities that fall within the definition of engineering/land surveying in the state of Idaho as defined in Idaho Code Section 54-1202 after the date of this Notice. I understand I cannot continue to use the “P.E./L.S.” title or designation. I hereby agree to not renew or seek reinstatement of said license to practice as a professional engineer/professional land surveyor in the state of Idaho. I further understand that this document is a public record, the Board shall have the right to make full disclosure of it, and IPELS records shall reflect this change in my license status.
_________________________________
Name of Licensee
ACCEPTANCE
The Idaho Board of Licensure of Professional Engineers and Professional Land Surveyors, through the Executive Director, accepts this Notice of Voluntary License Surrender, effective the date indicated above and according to the terms of this Notice.
DATED this _______ day of ______________________, 20__.
__________________________________
Keith Simila, P.E., Executive Director
M:\IPELS\!Forms\CURRENT STIPULATIONS Voluntary Surrender\!Voluntary Surrender lieu Discipline 2014.doc