* *This statement is for your information. Please do not send this to the Board.**
The Information Practices Act, Sec. 1798.17 Civil Code, requires the following information to be provided when collecting information from individuals.
Board for Professional Engineers, Land Surveyors, and Geologists
TITLE OF OFFICIAL RESPONSIBLE FOR INFORMATION MAINTENANCE:
2535 Capitol Oaks Drive, Suite 300, Sacramento, CA 95833-2944
AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION:
Sections 6700 to 6799, inclusive, comprising Chapter 7, Division 3, of the California Business and Professions Code, and Sections 8700 to 8805, inclusive, comprising Chapter 15, Division 3, of the California Business and Professions Code.
CONSEQUENCES OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED INFORMATION:
It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete.
PRINCIPAL PURPOSE(S) FOR WHICH THE INFORMATION IS TO BE USED:
The information requested will be used to determine qualifications for licensure or certification to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.
ANY KNOWN OR FORESEEABLE DISCLOSURES WHICH MAY BE MADE OF THE INFORMATION:
Your completed application becomes the property of the board and will be used by authorized personnel to determine your eligibility for a license or certification. Information on your application may be transferred to other governmental or law enforcement agencies. Pursuant to the California Public Records Act (Gov. Code Section 6250 et seq.) and the Information Practices Act (Civ. Code Section 1798.61), the names and addresses of persons possessing a license or registration may be disclosed by the department unless otherwise specifically exempt from disclosure under the law. Consequently, the personal name and address information entered on the attached form(s) may become public information subject to disclosure.
SOCIAL SECURITY NUMBER (SSN)/INDIVIDUAL TAX IDENTIFICATION NUMBER (ITIN) DISCLOSURE
Disclosure of your social security number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 [42 U.S.C.A. Section 405(c)(2)(C)] authorize collection of your social security number. Your social security number will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification of licensure or examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number, you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you. U.S. Citizens, if you do not have a social security number you may contact your local United States social Security Office at 1-800-722-1213. Non-U.S. citizens without a social security number may request an individual tax identification number from The Department of Treasury (Internal Revenue Service) at (215) 516-4846. Each individual has the right to review the files on records maintained on them by the agency, unless the records are exempt under Section 1798.40 of the Information Practices Act. You may gain access to the information by contacting the board at the above address.