CIVIL – OPTION 1
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P. L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798, et. seq.), notice is hereby given for the
request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the
processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information
will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect
all personal information in any record maintained on the individual by any identifying particular. Direct any inquires on information maintenance to your IPA Officer.
NAME (Print or Type)
Last
First
Middle
EMPLOYEE IDENTIFICATION NUMBER
S
OFFICE ADDRESS
DISTRICT/ UNIT
CLASSIFICATION
BARGAINING UNIT
SUPERVISOR’S NAME (print)
RANGE
PLANNED EXAM
DATE:
YEARS MONTHS (with Caltrans)
BUSINESS PHONE
HQ APPROVAL TO TAKE CLASSES
DATE
NATIONAL EXAM REVIEW COURSES (Maximum reimbursement $550)
E-FIS Reporting Code: G100053
The following courses are available. See vendor list for specific course details.
___ PPI2PASS (Kaplan)
___ ASCE
___ Civil Engineering Academy
___ Professional Engineering Services
___ Engineering Education and Training
___ School of PE
___ Excel Test Prep
___ Other (Prior Approval from HQ required)
___ PATH Civil Engineering Education
SEISMIC REVIEW COURSES
SURVEYING REVIEW COURSES
(Maximum reimbursement $300)
(Maximum reimbursement $300)
E-FIS Reporting Code: G100054
E-FIS Reporting Code: G100055
The following courses are available. See vendor list for specific course details.
___ Civil PE Surveying Review
___ Engineering Education & Training
___ Professional Engineering Services
___ Civil Surveying Review Workshop
___ School of PE
___ Engineering Education and Training
___ Seismic Design Review
___ Professional Engineering Services
___ Other (Prior Approval from HQ required)
___ School of PE
___ Other (Prior Approval from HQ required)
TECHNICAL PUBLICATIONS (Maximum Reimbursements: Civil Engr. = $250; Seismic = $150 & Surveying = $150)
The technical publications below are available for the above license types.
E-FIS Reporting Code: G100053
E-FIS Reporting Code: G100054/ G100055
___ Civil Engineering All-in-One PE Exam Guide
___ ASCE SEI 7-16
___ CA Civil Surveying Reference
___ Civil Engineering Reference Manual
___ IBC / CBC
___ Other (prior approval required)
___ NCEES PE Civil Practice Exam(s)
___ Seismic Design Review Workbook
___ Practice Problems for CE PE Exam
___ 345 Solved Seismic Design Problems
___ Six Minute Solutions for Civil PE Exam
___ Civil Surveying Review
___ Other (Prior Approval from HQ required)
___ Surveying Principles for Civil Engineers
I hereby certify that I have read and understand the guidelines governing the Professional Licensing Assistance Program
and requirements, and am aware that this is a one time only assistance by the Department.
EMPLOYEE (Signature)
DATE
HQ PROFESSIONAL DEVELOPMENT APPROVAL FOR PAYMENT
Unit
Project
Phase
3422
3422
3422
0000000810
0000000810
0000000810
N
N
N
DATE
E-FIS Reporting
Object
G100053
G100054
G100055
075
075
075
Amount
$
$
$
FY
0
