The Board of Governors of the Licensed Architects

BOARD OF GOVERNORS OF THE LICENSED ARCHITECTS LANDSCAPE ARCHITECTS AND REGISTERED INTERIOR DESIGNERS OF OKLAHOMA P.O. Box 53430, Oklahoma City, OK 73152 Overnight Mailing Address * Office Location: 220 NE 28th Street, Suite 150, Oklahoma City, OK 73105 PHONE (405) 949-2383 FAX (405) 949-1690 Address Correction Requested

Full Name: ______Address: ______License #: ______

THIS FORM MUST BE RETURNED. COPIES WILL NOT BE ACCEPTED. Renewal fee for two-year period July 1, 2017 thru June 30, 2019 RENEWAL FEE - $325.00

The $325.00 biennial renewal fee is due by 4:30 p.m. in the Board office on or before June 30, 2017. This is a two (2) year License renewal fee. Postmarks will not be accepted. All Licenses are canceled July 1, 2017. Payment made on or after July 1 st will require an additional late payment/reinstatement penalty of $225.00 . Your canceled check will serve as your receipt. MAKE CHECKS PAYBLE TO OKLAHOMA BOARD OF ARCHITECTS. You are required to complete the following information to renew. READ CAREFULLY!

1. ___YES ___ NO I am currently licensed and in 5. Oklahoma residents only may qualify for Emeritus good standing in my base state/and or state of status: residency, which is ______This status requires no renewal fee and only applies to 2. ___YES ___ NO Have you been investigated, residents of Oklahoma and who have been licensed in charged, or disciplined since 6/30/2015, or are you this state for ten (10) consecutive years, sixty-five (65) currently under investigation by any governing or years of age or older and retired from active practice. licensing board or by any state or federal agency? If You must re-apply for this status each renewal period. yes, submit details. Contact Board office for application.

3. ___ YES ___ NO Have you been charged, arrested, 6. ___YES ___ NO Do you contract using your convicted, found guilty or pleaded nolo contendre to firm name in Oklahoma? (If "no" skip to #9) any criminal offense in any state since 6/30/2015 (excluding non-criminal traffic infractions)? If yes, 7. Firm Name: submit details. «FirmName»

4. CONTINUING EDUCATION: 8. Your LEGAL position in the firm: [Check one] o General Partner ___ I certify and affirm that I have participated in the o Director continuing education activities as submitted during the o Partner period July 1, 2015 to June 30, 2017. [Complete back o Officer of form or attach transcript] o Principal o Shareholder ___ I certify and affirm that I am exempt from the o Manager [applies to LLC] continuing education for the following reason (55:10- Member [applies to LLC] 17-5): [Check one] o Employee o First Time Licensee o o Active Duty Military Duty Personnel 9. Email address: o Hardship Status (attach letter) «Email» o Retired from active practice (Emeritus) ______

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

______[Licensee Signature] [Date]

____ I DO NOT WISH TO RENEW ______[Licensee Signature] [Date]