published by the oregon state board of...

Fall 2012

The mission of the Oregon State Board of Examiners for Engineering and Land Surveying (OSBEELS) is to regulate the practice of engineering, land surveying, photogrammetric mapping, and water right certification in the state as they relate to the welfare of the public in safeguarding life, health and property.

Board MembersSue E. Newstetter, PLS, PresidentWilliam J. Boyd, Public MemberSteven A. Burger, PE Shelly MC Duquette, PEKen W. Hoffine, PE/PLS/CWREJason J. Kent, PERon Singh, PLSDave M. Van Dyke, PEAmin Wahab, Public MemberOscar J. Zuniga, PE

Board StaffMari Lopez, AdministratorJenn Gilbert, Executive AssistantAdaira Floyd Veronica GloriaJennifer O’NeillMonika PetersonTina SorensenAmelia VolkerBrianna WeeklyJ.R. Wilkinson

Inside This Issue1-2 Returning Board Member 3 Online License and Exam Vertification System

4-5 Examiniation Statistics 6-8 Investigation and Enforcement 9-10 Renewal Form

Returning Board MemberOSBEELS Welcomes Back Amin Wahab

PUBLISHED BY THE OREGON STATE BOARD OF EXAMINERS FOR ENGINEERING AND LAND SURVEYING

ExaminerThe Oregon

See RETURNING BOARD MEMBER, Page 2

Winter 2015

Amin Wahab, Public Member, was re-appointed by Governor John.A. Kitzhaber,

MD, to the Oregon State Board of Examiners for Engineering and Land Surveying (OSBEELS) as a Public Board Member in October 2014. Previously, he served as a Board member from June 2007 to May 2013. Mr. Wahab resigned his membership with OSBEELS and also was granted a one-year leave from his position with the City of Portland to take a one-year assignment as the Water Technical Lead with the United States Agency for International Development (USAID) Office of Agriculture at USAID Mission in Kabul, Afghanistan. Mr. Wahab returned to Oregon in late June 2014.

“My [experience] as the Water Technical Lead with the USAID Mission in Afghanistan has given me a fresh perspective

on the role oversight bodies play to safeguard public trust and resources, and ensure ethics in the practice of engineering and land surveying.”

Upon returning to Oregon, Mr. Wahab resumed his current position as an Environmental/Watershed Program Manager for the City of Portland Bureau of Environmental Services (BES). The position has provided him with a valuable skill set in land use, water, watershed management, transportation and sustainability. In addition to the managerial components of his work for the City of Portland BES as the Fanno and Tryon Creek Watershed Manager, Mr. Wahab has provided technical and policy support in environmental analysis, land use planning and development reviews. In addition, his position includes investigating facilities and recommending corrective action

Winter 2015 Oregon Examiner.indd 1 2/19/2015 2:56:13 PM

Fall 2012T h e O r e g o n E x a m i n e r

Page 2

Winter 2015

RETURNING BOARD MEMBER, from Front Page

and coordinating with engineering services on tasks related to project budgeting, design, permitting and construction. The role also includes project evaluation for consistency with applicable City policies and State and Federal water quality/environmental regulations, among other responsibilities.

Mr. Wahab has held positions with the State of Oregon Water Resources Department and the Port of Portland in the past. His other skill areas include technical and policy support in environmental analysis, land use planning and development reviews, analyzing resource policy and technical issues to recommend amount, rate or season of use, assessing river basin conditions to develop basin plans, water appropriation programs, with projects including the Willamette and Sandy Rivers. Mr. Wahab also has experience conducting field investigations of water rights, use permits and water use.

Mr. Wahab’s experience in natural resources, as well as recent time spent abroad, will help provide a fresh perspective on matters the Board may face.

When it comes to the OSBEELS mission: safe-guarding the life, health and property of the people of Oregon, he is passionate about serving the state.

“I am a strong advocate for sound engineering practices in order to assure the best infrastructure for sustained economic development.”

After spending time in his field and managing detailed projects, Mr. Wahab is looking forward to playing a constructive and effective role on the Board by representing the public.

Keeping active in the natural resource community, he takes part in various associations and participates

in seminars and publications relating to his practice. Throughout his career, Mr. Wahab has been part of many professional affiliations, including the Water Environment Federation, Oregon Association of Clean Water Agencies, Pacific Northwest Clean Water Association, River Management Society of North America and the Northwest Association of Environmental Professionals. He has served on other Committees and Task Forces including the City of Lake Oswego Surface Water Management Plan and Foothills Development Technical Advisory Committees.

Mr. Wahab completed his Engineering Technology degree at the Afghan Institute of Technology and continued his engineering studies at Kabul University (Kabul, Afghanistan) until his studies were interrupted by political turmoil. Mr. Wahab continued to pursue his BS and MS degrees in Physical/Resource Geography from Oregon State University, with a minor in Integrated Geography. His studies included a variety of subjects, including land and water resource processes, development, impact, management and conservation. Other topics included transportation and economic planning. Most recently, Mr. Wahab was awarded a graduate certificate in transportation with a sustainability focus from the Portland State University Center for Transportation Studies.

OSBEELS is pleased to welcome back Mr. Amin Wahab, Public Member, to the Board.


T h e O r e g o n E x a m i n e rWinter 2015

RETURNING BOARD MEMBER, from Front Page

Online License and Exam Vertification SystemNCEES Stats Update

NCEES officially launched a new license and exam verification system in March 2013, allowing registrants to select the Board they

are making an application to and submit a license and/or exam verification. Since the launch in 2013, a steady increase in use of the online system has been reported. As of 18 months since the launch, NCEES reported that around 35,000 verifications have been completed through the system, with the highest week showing 150 completed verifications. 18,670 verifications have been completed for the

NCEES Records Program and 16,026 verifications have been completed directly from Board to Board. As of December 2014, 55 Boards currently participate in the program, including OSBEELS. To complete the process, first request verification of your license and examination information through the NCEES License/Exam Verification system and complete the OSBEELS Verification Payment Form at www.oregon.gov/Osbeels/docs/Form/2013_Verification_Payment_fillable.pdf

Boards currently participating in the license and exam verification system:

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida (Engineering)

Florida (Land Surveying)

Georgia

Hawaii

Idaho

Illinois (Engineering)

Illinois (Structural Engineering)

Illinois (Land Surveying)

Indiana (Engineering)

Indiana (Land Surveying)

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska (Engineering)

Nebraska (Land Surveying)

Nevada

New Hampshire (Engineering)

New Hampshire (Land Surveying)

New Mexico

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Rhode Island (Engineering)

Rhode Island (Land Surveying)

Tennessee

Texas (Engineering)

Texas (Land Surveying)

Utah

Virginia

Virgin Islands, U.S.

Washington

West Virginia (Engineering)

West Virginia (Land Surveying)

Wyoming


Examination Statistics

T h e O r e g o n E x a m i n e r Winter 2015

See EXAMINATION STATISTICS, Page 5

20%

40%

60%

80%

100%

January 2014 - November 2014 Fundamentals ExamFirst Time Takers

FE

90%

77%

Oregon % PassedNational % Passed

FLS

100%

54%

317 examinees 363 examinees7 examinees 17,445 examinees

20%

40%

60%

80%

100%

January 2014 - November 2014 Fundamentals ExamRepeat Takers

27%

35%

14%


FE FLS15 examinees 139 examinees1 examinee3,838 examinees

0%

20%

40%

60%

80%

100%

April 2014 Professional Surveying ExamRepeat Takers

67%

37%

____%


PLS Oregon Speci�c (4-hour)3 examinees 5 examinees147 examinees

____%

80%

20%

40%

60%

80%

100%

April 2014 Professional Surveying ExamFirst Time Takers

PLS

67% 69%


Oregon Speci�c (4-hour)

76%

6 examinees 17 examinees348 examinees


T h e O r e g o n E x a m i n e rT h e O r e g o n E x a m i n e rWinter 2015

EXAMINATION STATISTICS, from Page 4

20% 40% 60% 80% 100%

Chemical

Electrical

Environmental

Mechanical

Civil

April 2014 Professional Engineering Examination StatisticsFirst Time Takers

Oregon % Passed National % Passed

Structural- Vertical

Structural-Lateral

71%

87%70%

47 examinees4,228 examinees

11 examinees772 examinees





73%68%

75%51%

82%72%

40%44%

50%46%

3 examinee187 examinees

67%

20% 40% 60% 80% 100%

Chemical

Electrical

Environmental

Mechanical

Civil

April 2014 Professional Engineering Examination StatisticsRepeat Takers

Oregon % Passed National % Passed

Structural- Vertical

Structural-Lateral

24%

54%39%







83%43%

33%28%

75%40%

50%23%

50%38%

1 examinee74 examinees

NOTE: The Acoustical, Control Systems, Fire Protection and Geotechnical Professional Engineering Examinations are offered in

October only and therefore do not appear this Newsletter’s Examination Statistics. For questions relating to any examination,

including important application deadlines and costs, please visit: www.oregon.gov/Osbeels/Pages/registration.aspx


See ENFORCEMENT, Page 7

Investigation and EnforcementLaw enforcement cases with sanctions from July 8, 2014 to Sep. 9, 2014

2762 – Ramasurdyal Premsingh

The Board issued a Final Order against Ramasurdyal Premsingh, finding that he failed to obtain the required number of PDH units during the audit period of July 1, 2008 – June 30, 2010, failed to provide adequate supporting CPD documentation, and failed to cooperate with the Board. Mr. Premsingh entered into a settlement agreement to pay a civil penalty of $500 for violations of OAR 820-010-0635(1)(a)&(c), and OAR 820-020-0015(8).

2789 – Jerry Wayne Alber

The Board issued a Default Final Order against Jerry Wayne Alber, finding he failed to submitdocumentation in support of the PDH units claimed for renewal during the audit period of January 1, 2010 – December 31, 2011. Mr. Alber was assessed a $500 civil penalty for violation of OAR 820-020-0015(8).

2796 – Sonia Anne Hennum

The Board issued a Default Final Order against Sonia Anne Hennum, finding that she failed to cooperate with the Board by not responding to three attempts by the Board to gain her compliance

with an audit of the PDH units she reported for the audit period of July 1, 2009 – June 30, 2011. Ms. Hennum was assessed a $500 civil penalty for violation of OAR 820-020-0015(8).

2799 – Leonard Charles Knapp

The Board issued a Default Final Order against Leonard Charles Knapp, finding that he failed to produce documentation to support continuing education reported for the audit period of July 1, 2009 – June 30, 2011. Mr. Knapp was assessed a $1,500 civil penalty and a 30-day suspension of his PE registration for the violations of OAR 820-020-0015 (8) and theformer OAR 820-010-0635.

2801 – David W. Kreighbaum

The Board issued a Final Order against David W. Kreighbaum, finding that he failed to cooperate with the Board during an audit of his PDH units due to a failure to report an address change for the audit period of July 1, 2009 – June 30, 2011. Mr. Kreighbaum entered into a settlement agreement to pay a civil penalty of $250 for violation of OAR 820-010-0605.

2807 – David Charles Weiss

The Board isued a Final Order against David Charles Weiss, finding that he failed to cooperate with the Board during an audit of his PDH units and failed to maintain his professional development during the audit period of July 1, 2008 – June 30, 2010. Mr. Weiss entered into a settlement agreement to permanently retire his PE registration without the possibility of reinstatement in lieu of a civil penalty for violations of OAR 820-020-0015(8) and former OAR 820-010-0635(1).

2808 – Gerald Zadikoff

The Board issued a Final Order against Gerald Zadikoff, finding that he failed to cooperate with the Board during the audit period of July 1, 2008 – June 30, 2010. Mr. Zadikoff entered into a settlement agreement to permanently retire his PE registration without the possibility of reinstatement in lieu of a civil penalty for violations of OAR 820-020-0015(8).



T h e O r e g o n E x a m i n e r

ENFORCEMENT, from Page 6


2819 – Scott T. Ogren

The Board issued a Default Final Order against Scott T. Ogren, finding he failed to cooperate with the Board on several occasions, failed to be truthful with the Board, engaged in the practice of engineering and used an engineering seal while his registration was in delinquent status, and for falsifying his renewal date. Mr. Ogren was assessed a $5,750 civil penalty for violations of OAR 820-020-0015(8), ORS 672.020(1), OAR 820-010-0620, OAR 820-020-0025(1) and ORS 672.045(1)&(2).

2821 – David George Sanders

The Board issued a Default Final Order against David George Sanders, finding he failed to cooperate with the Board by not responding to three attempts by the Board to gain his compliance with an audit of the PDH units he reported for the audit period of July 1, 2010 – June 30, 2012. Mr. Sanders was assessed a $500 civil penalty for violation of OAR 820-020-0015(8).

2822 – John Robert Marks

The Board issued a Default Final Order against John Robert Marks, finding that he failed to respond in a request for his participation in a

PDH audit during the audit period of January 1, 2009 – December 31, 2010. Additionally, the Board found he failed to comply with CPD requirements. Mr. Marks was assessed a $1,500 civil penalty and 60-day suspension for violations of OAR 820-020-0015(7)&(8), and the former OAR 820-010-0635(1)&(5).

2823 – Stephen Leo Steiner

The Board issued a Default Final Order against Stephen Leo Steiner, finding that he failed to respond to several attempts by the Board to gain compliance with his audit. Additionally, Mr. Steiner failed to produce documentation to support continuing education reported for the audit period of January 1, 2009 – December 31, 2010. Mr. Steiner was assessed a $1,500 civil penalty and a 60-day suspension of his PLS registration for violations of OAR 820-020-0015(7)&(8) and former OAR 820-010-0635.

2824 – Daejoong Kim

The Board issued a Default Final Order against Daejoong Kim, finding that he failed to respond to the Board’s multiple audit requests. Upon contact he was able to submit the required CPD documentation, however; he failed to update his pesonal contact

information, including changes to his employer’s address. Mr. Kim was assessed a $250 civil penalty for violation of OAR 820-010-0605(1).

2825 – Naoki Niwa

The Board issued a Default Final Order against Naoki Niwa finding that he failed to cooperate with the Board over a period of fourteen months by not responding to a number of attempts by the Board to gain compliance with a CPD audit. Once contacted, Mr. Niwa was unable to produce CPD documentation. Mr. Niwa was assessed a $1,500 civil penalty and a 60-day suspension of his PE registration for the violations of OAR 820-020-0015(7)&(8) and former OAR 820-010-0635.

2829 – Jack L. Watson

The Board issued a Final Order against Jack L. Watson, finding that he failed in his dependent resurvey of an original federal government survey to practice due diligence by placing sections and quarter-sections in the same places established during an 1884 federal survey, which stood as the legal permanent corners; failed to practice due diligence in reestablishing those corners at the identical spots where they were





originally located; and failed to reestablish those corners with adequate reference to the BLM Manual of Instructions for the Survey of the Public Lands of the United States (1973). Mr. Watson entered into a settlement agreement to pay a civil penalty of $1,000 for violation of ORS 209.250(1) (1993), former ORS 209.200(1), (2)&(3) (1989) and former ORS 209.070 (1989).

2834 – Timothy A. Hagedorn

The Board issued a Default Final Order against Timothy A. Hagedorn, finding that he failed to update his address with the Board. Mr. Hagedorn was assessed a $250 civil penalty for the violation of OAR 820-010-0605.

2835 – Donald E. Marx, Jr.

The Board issued a Default Final Order against Donald E. Marx, Jr, finding he practiced land surveying without being registered with the Board and falsely represented his authorization to practice. Mr. Marx was assessed a $2,000 civil penalty for violations of ORS 672.025(1) and ORS 672.045(1)&(2).

2838 – Bradley Thurman Stiles

The Board issued a Default Final Order against Bradley

Thurman Stiles, finding that he failed to cooperate with the Board during an audit of his PDH units for the audit period of July 1, 2010 – June 30, 2012. Mr. Stiles was assessed a $500 civil penalty for violation of OAR 820-020-0015(8).

2842 – Marshall Robert Pihl

The Board issued a Default Final Order against Marshall Robert Pihl, finding that he failed to cooperate with the Board during an audit of his PDH units for the audit period of Jan 1, 2011 – December 31, 2012. Mr. Pihl was assessed a $500 civil penalty for violation of OAR 820-020-0015(8).

2843 – Won-Jin Sung

The Board issued a Default Final Order against Won-Jin Sung, finding that he failed to update his address with the Board. Mr. Sung was assessed a $250 civil penalty for violation of OAR 820-010-0605.

2844 – David Gregory Dickoff

The Board issued a Default Final Order against David Gregory Dickoff, finding that he falsely represented himself as a professional engineer by not stating that his registration was in retirement status during public

testimony. Mr. Dickoff was assessed a $500 civil penalty for violation of ORS 672.045(2).

2845 – Timothy A. Wolden

The Board issued a Final Order against Timothy A. Wolden, PE, finding that he violated the Settlement Agreement in Board case #2781, ORS 672.045(1), and OAR 820-010-0520. In case #2781, the Board suspended Mr. Wolden’s professional engineer registration for 45 days and assessed a $16,000 civil penalty, $8,000 of which was abated pending no further violations, when the Board found Mr. Wolden was negligent and violated the rules of professional conduct in eight instances by performing and certifying engineering works not done incompliance with the City of Eugene Fire Marshal’s Office Fire Escape Testing and Maintenance Policy 08-08 and by determining that the eight fire escapes were structurally safe without performing an approved load test process. Mr. Wolden was untruthful in those eight instances when he sealed and signed documents indicating that he had tested the fire escapes and determined them to be structurally safe according to the



See RENEWAL FORM, Page 10

Renewal Form

T h e O r e g o n E x a m i n e r


Registrant Contact InformationFirst name (personal name) Middle name or initial Last name (family name)

If you have a Social Security number Oregon law requires that it be used. Only use a Passport number if you don’t have a Social Security number.

o Social Security # OR o Passport # Country issuing passport Registration Number

Birth date (Mo/Day/Yr) Where do you want correspondence mailed to? o Home address OR o Business address

Home address (include any apartment number) Home/Personal phone #

City State Zip/Postal code Home email address

Business name Business phone # Business fax #

Business address (include any suite number)

City State Zip/Postal code Business email address

Social Security GuidelinesAs part of your application for an initial or renewed occupational, professional or recreational license, certification, or registration issued by OSBEELS, you are required to provide your Social Security Number to OSBEELS. This is mandatory. The authority for this requirement is ORS 25.785, ORS 305.385,42 USC § 405 (c) (2) (C) (I), and 42 ISC § 666 (a) (13). Failure to provide your Social Security Number will be a basis to refuse to issue or renew the license, certification, or registration you seek. This record of your Social Security Number will be used for child support enforcement and tax administration purposes (including identification) only, unless you authorize other uses of the number. Although a number other than your Social Security Number appears on the face of the licenses, certificates, or registrations issued by OSBEELS, your Social Security Number will remain on file with OSBEELS.

If, the United States Social Security Administration has not issued you a social security number, you must follow these guidelines:a. form must be signed by you; b. You are attesting to the fact that no social security number has been issued to you by the United States Social Security Administration; andc. are acknowledging that knowingly supplying false information under this section is a Class A misdemeanor, punishable by imprisonment of up to one year and a fine of up to $6,250.

By providing the following signature, you are agreeing to comply with the guidelines listed above.Signature Date (Mo/Day/Yr)

Address for public disclosure (As per Oregon Revised Statute (ORS) Chapter 192) o Same as mailing address

City State Zip/Postal code

If requesting reinstatement from inactive or retired status, please complete the Reinstatement from Inactive or Retirement Status form available at www.oregon.gov under the “Registration” tab.



Renewal Form ContinuedRENEWAL FORM, from Page 9

I certify that I have completed the required professional development hour (PDH) units in accordance with the applicable OARs.

Signature Date (Mo/Day/Yr)

o Delinquency fee per registration renewal: $80.00 each profession o PE o PLS o RPP o CWRE

Please refer to the OAR 820-010-0505 and OAR 820-010-0520 for further details.

Please check the applicable boxes and enclose the appropriate amounto Active registration renewal: $150.00 each profession o PE o PLS o RPP o I have attached the CPD Organizational formo I have attached the Continuing Education Request for a

Grace Period form

o Certified Water Right Examiner (CWRE) renewal: $40.00For PE or PLS registrants, please refer to OAR 820-050-0010(1)(b)

For a Registered Geologist (RG) holding a CWRE: o I have attached the CPD Organizational formo I have attached the Continuing Education Request for a

Grace Period form

Please refer to the Oregon Administrative Rule (OAR) 820-010-0505, OAR 820-010-0510, OAR 820-010-0635 and OAR 820-015-0026 for additional details.

Please refer to the Oregon Administrative Rule (OAR) 820-050-0001 and OAR 820-050-0010 for additional details.

If submitting a payment to the OSBEELS for fees by debit or credit card, please provide the security code. These codes are a security feature that appears on the back of most Visa, MasterCard, and Discover cards, and on the front of American Express cards. American Express Card Users: Look for the 4-digit code printed on the front of the card just above and to the right of the main card number. This 4-digit code is the card security code. Visa, MasterCard, and Discover Card Users: Flip the card over and look at the signature box. A special 3-digit code will be located in the signature box. This 3-digit code is the card security code.

* Debit or Credit Card Security Codes

Select payment method (choose one)o Check or Money Order (payable to OSBEELS) o Cash Amount enclosed:

o Debit or Credit Card (Visa, Mastercard, Discover, or AmEx) Total charge to card:

Card number Exp. date Security code* Billing Zip/Postal code

Payment Signature (serves as payment authorization if paying by debit or credit card)Signature Date (Mo/Day/Yr)

Please indicate how you would like to receive the OSBEELS newsletter, The Oregon Examiner. o Primary Address o Primary Email o Business Address o Business Email o No Newsletter

The Oregon Examiner Newsletter



Registration renewalNot sure if your registration(s) is current? Visit the OSBEELS website at www.oregon.gov/osbeels and click on the “Find a Licensee” link to confirm your registration(s) status.

Employer ChecksIf your employer sends a check for your renewal, please ensure that it includes your registration number(s) and your Continuing Professional Development

Organizational Form is attached. If these items are not included, it will delay the renewal process.

Social Security Number To comply with child support enforcement and tax administration law, OSBEELS requires that all applicants and licensees provide their Social Security numbers. The Oregon Revised Statute (ORS) 25.785, specifically requires that the Social Security number be recorded on an application for,

or form for renewal of, a license, certificate or registration. If you have not been issued a Social Security number, OSBEELS will accept a written certification to fulfill this requirement.

Deceased RegistrantsIf you are aware of a registrant who has passed on, please call (503) 362-2666. OSBEELS would like to avoid sending renewal notices and other communications to the families.

Friendly Reminders


approved load test process when, in fact, he had not tested the fire escapes and determined them to be structurally safe according to the approved load test process. In case #2845, Mr. Wolden was found practicing engineering on two occasions during his suspension period. The Board issued a Final Order suspending Mr. Wolden’s registration for 180 days, enforced the abated $8,000 civil penalty from case #2781, and assessed an additional $2,000 for two instances of unlicensed practice in violation of ORS 672.045(1), and OAR 820-010-0520.

2857 – United Engineering, Inc.

The Board issued a Default Final Order against United Engineering Inc., finding that United Engineering

Inc. falsely advertised and offered to practice engineering, falsely represented they were authorized to practice engineering, and practiced engineering without a full-time employee, partner, manager, or officer licensed to practice engineering in Oregon. United Engineering Inc. was assessed a $1,000 civil penalty for violations of ORS 672.045(1)&(2) and OAR 820-010-0720.

2861 – Richard Alan Brown

The Board issued a Default Final Order against Richard Alan Brown, finding that he failed to report a change of address to the Board within 30 days of relocating. Mr. Brown was assessed a $250 civil penalty for the violation of OAR 820-010-0605.

2866 – Alex Nikolakopulos

The Board issued a Default Final Order against Alex Nikolakopulos, finding that he failed to cooperate with the Board by not responding to a number of attempts by the Board to gain compliance with a PDH audit. In addition, Mr. Nikolakopulos failed to produce documentation to support continuing education reported for the audit period of January 1, 2011 – December 31, 2013. Mr. Nikolakopulos was assessed a $1,500 civil penalty and a 60-day suspension of his PE registration for the violations of OAR 820-020-0015(7)&(8) and the former OAR 820-010-0635.



BOARD OF EXAMINERSFOR ENGINEERING &LAND SURVEYING

670 Hawthorne Avenue, SESuite 220Salem, Oregon 97301

tel. 503.362.2666email: [email protected]

web: www.oregon.gov/osbeelsWin

ter

2015

To receive the newsletter electronically, please provide an email address below. If you would prefer to receive the newsletter in print rather than electronically or at a different mailing address, please provide the preferred mailing address below. If you are already receiving the newsletter in the preferred format and at the correct location, submission of this form is not necessary.You may return this form by email to [email protected], by fax to (503) 362-5454 or by mail to the address listed above. Please note, the contact information in which Board correspondence is sent will not be changed by submitting this form. Please utilize the Name/Address Change form to comply with Oregon Administrative Rule (OAR) 820-010-0605.

Registrant Information

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Email Address Registration or certificate number, if applicable

To receive the print edition of The Oregon Examiner, please complete the information below.

o Home o Business

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