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Home My WebLink About210037 06/20/2012 CITY OF CARMEL, INDIANA VENDOR: 360375 Page 1 of 1 ONE CIVIC SQUARE INDIANA PROFESSIONAL LICENSING CARMEL, INDIANA 46032 402 W WASHINGTON ST ROOM W072 CHECK AMOUNT: $200.00 INDPLS IN 46204 CHECK NUMBER: 210037 CHECK DATE: 6/20/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4355300 200.00 REDDEN /DUNCAN Indiana Professional Licensing Agency We work to State Board of Registration for Professional Engineers keep you working 402 W. Washington St. Room W072 Indianapolis, IN 46204 L A Professional Licensing Agency Nicholas Joseph Redden 7219 West 75 South Lafayette IN 47909 -9263 Please return this entire page to the address above after answering all questions and signing the form failure to do so will delay your renewal. Be sure to enclose your renewal fee. Make checks payable to: Indiana Professional Licensing Agency. Reeistration M—lber Date Esnfr na es Renel Fee Nicholas Joseph Redden 07/31/2012 $100,00 7219 West 75 South E Lafayette IN 47909 -9263 SINCE YOU LAST RFNEWED: Kt— to any gtiestion, attach documentation and resolution of action(- O LL Has any professional license, certificate, registration, or permit you hold or have held t. een disciplined nr are formal charges pending? }'E_ c NO d Enter Chantie of Address: 2• Have you been denied a license, certificate, registration or permit in any state? }mac NO W 4 (lave you been convicted of or pled guilty to a violation of a federal or state law— or are Q to criminal charges pending? YES NO C y .NS W F R C E Oue,,i iorn Bel-- Have )-on met the continuing education req uirement to renew Active see below If Active and CE requirement is not met do you want to renew as INACTIVE? YES NO _e You must sign and date below. By signing this form you are attesting that the information on this renewal is true and correct and that you have met all required continuing education hours if applicable C W I If this form is not com ileted correctly, it will be returned and your renewal will be delaved. 1 hereby s -ear or affaan under the penalties of perjruy that I Si rahrre O A li rit )ate Siened mrtlerstand and have answered the question true to the best of my lax -ledge. Q Enter E -mail Address: ADD,4 LATE FEZ of $50 it PO RKED AFTER 07/31/2012 IF YOU ANSWERED "YES" to questions 1 to 3 above• you must provide a signed statement that explains all the related details. You must include the violation• location. date, and disposition. Letters from attorneys. insurance companies, court document-, or other relevant documentation should be included with your statement. Be sure to write your name and registration number on all documents. ONLINE RENEWAL Renewing online is quick, simple, and is the fastest way for your registration to be renewed! To renew online, go to wnnv.nla.in.eov l'our login ID i.c Motu• registration number. I'ourpacsword is the last j6ur digits of your social securith number. You can update your address and other demoarlphic information during your renewal or any other time by logging in to your records online. *.ACTIVE STATUS Pursuant to IC 25 -31 -1 -17.5 and 864 IAC 1.1 -15. to renew in "ACTIVE" status• a registrant whose registration was issued prior to August 1, 2010 must obtain thirty (30) hours of continuiuEZ education (CE): a new registrant whose registration was issued August 1. 2010 July 31.2011 must obtain fifieen (15) hoots of CE: a new registrant whose registration was issued from August 1. 2011 July 31, 2012 is not required to obtain CE. Ifyou hold an "ACTT\ E" registration and have NOT completed the CE requirements necessary to renew the registration in "ACTIVE" status, you can only renew your registration under the "INACTIVE" status or not renew at all. A registrant on "INACTIVE" status may not practice. All fees are non refundable INACTIVE STATUS If yourcun'ent registration status is "INAC'TIVE you must renew the registration under that same status. Ifyou wish to change the status from "INACTIVE" to "ACTIVE you will need to contact the board and request an Application for Reactivation of Inactive Registration. In "INACTIVE" status, you are not required to complete the CE requirements. To activate an inactive registration• you must comply with 864 IAC 1.1- 15 -10. QUESTIONS Contact us by email at n1al0(iix.la.in.eov or by phone at (317) 234 -3022. Phones may be busy during renewals. Please be patient. Indiana Professional Licensing Agency M We work to State Board of Registration for Professional Engineers keep you working am 402 W. Washington St. Room W072 AM mum Indianapolis, IN 46204 P L #4 Professional Licensing Agency PROFESSIONAL ENGINEER REGISTRATION RENEWAL APPLICATION Please return this entire page to the address above after answering all questions and signing the form failure to do so will delay your renewal. Be sure to enclose your renewal fee. Make checks payable to: I ndiana Professional L ice ing Ag ency. Name Registration Number Date Expires Renewal Fee oV'MUN o f �Q 9'�0 7/31 /2012 $1 00.00 r" Answer all questions below by circling the correct response: 1. Since you last renewed, has any professional license, certificate, r=3 registration, or permit you hold or have held been disciplined YES NO or are formal charges pending? nci Current Address o, 2. Since you last renewed, have you been denied a license, YES O ca certificate, registration or permit in any state? PA14770+ CaAT 3. Have you been convicted of or pled guilty to a violation of a YES NO =a /IJ 4625b federal or state law or are criminal charges pending? I t'JI �YN�Pdi t ANSWER CE Questions Below: 'W Have you met the continuing education requirement to renew (Y3ENO N/A in "Active" status (see below w sQ If your registration is on "Active" status and your CE requirement YES 1NU Z is not met do you want to renew as INACTIVE? J O You must sign and date below. By signing this form, you are attesting that the information on this renewal is true and correct and that you have met all required s continuing education hours, if applicable. If this form is not completed correctly it will be returned, and your renewal will be delayed. Si na Of A licant es and Yes or No to all uestions Date Signed 1 hereby swear or affirm under the penalties of g perjury that I understand and have answered the questions true to the best of my knowledge. E -mail Address: ADD�A ATE FEE of $50 tf r t r� 1POSTMARKED�'AF7 d uncan G� Carmel. m. v V J 31 <2 5 v IF YOU ANSWERED "YES" to questions 1 -3, you must provide a signed statement that explains all the related details. You must include the violation, location, date, and disposition of the event. Letters from attorneys, insurance companies, court documents, or other relevant documentation should be included with your statement. RENEW ONLINE! Renewing online is quick, simple, and is the fastest way for your registration to be renewed! To renew online, go to www.l)la.in.gov Your login ID is your registration number. Your password is the last four digits of your social security number. You can update your address and other demographic information during your renewal or any other time by logging in to your records online. *ACTIVE STATUS Pursuant to IC 25 -31 -1 -17.5 and 864 IAC 1.1 -15, to renew in "ACTIVE" status, a registrant whose registration was issued prior to August 1, 2010 must obtain thirty (30) hours of continuing education (CE); a new registrant whose registration was issued August 1, 2010 July 31,2011 must obtain fifteen (15) hours of CE; a new registrant whose registration was issued from August 1, 2011 July 31, 2012 is not required to obtain CE. If you hold an "ACTIVE" registration and have NOT completed the CE requirements necessary to renew the registration in "ACTIVE" status, you can only renew your registration under the "INACTIVE" status or not renew at all. A registrant on "INACTIVE" status may not practice. All fees are non refundable INACTIVE STATUS If your current registration status is "INACTIVE you must renew the registration under that same status. If you wish to change the status from "INACTIVE" to "ACTIVE you will need to contact the board and request an Application for Reactivation of Inactive Registration. In "INACTIVE" status, you are not required to complete the continuing education requirements. To activate an inactive registration, you must comply with 865 IAC 1- 15 -14, 8651AC 1- 15 -15, or 865 IAC 1- 15 -16. QUESTIONS Please contact us by email at pla10 @pla.in.gov or by phone at (317) 234 -3022. During renewals, our phones can be very busy and there may be a long wait. EXPIRED REGISTRATIONS If your registration has been expired for LESS than 3 years you may submit this application with the late fee, and proof of having completed your required CE to renew in "ACTIVE" status. If your registration has been expired for MORE than 3 dears you will need to contact our office by email at pla 10 @pla.in.gov or by phone at (317) 234 -3022. Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price` "er unit, etc. Payee Indiana Professional Licensing Agency t f Purchase Order No. 402 W Washington St. Room W072 Terms Indianapolis, IN 46204 Date Due Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s) Amount 1/0/1900 0 PE renewal Nick Redden 100.00 1/0/1900 0 PE renewal Gary Duncan 100.00 Total 200.00 I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. ,20 Clerk- Treasurer VOUCHER NO WARRANT NO. Indiana Professional Licensing Agency ALLOWED 20 402 W Washington St. Room W072 IN SUM OF Indianapolis, IN 46204 200.00 ON ACCOUNT OF APPROPRIATION FOR Board Members PO #or INVOICE NO. ACCT /TITLE AMOUNT DEPT# I hereby certify that the attached invoice(s), or 0 195,0,00 0 100 bill(s) is (are) true and correct and that the materials or services itemized thereon for 0 0 100 which charge is made were ordered and received except O 6/18/2012 Signat Cost Distribution ledger classification if Title claim paid motor vehicle highway fund