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Association of Professional Engineers of Ontario40 Sheppard Ave. West, Suite 101Toronto, ON, M2N 6K9Tel:(416) 224-1100; (800) 339-3716Fax:(416) 224-8168; (800) 268-0486http://www.peo.on.ca

Application Number: 100188674

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Application: Application for FCP (Web Only)Application Date: 03/08/2012 (dd/mm/yyyy)

Personal DetailTitle: Mr.

First Name: Daniel

Last Name: Camball

Birthdate: 13/04/1989 (dd/mm/yyyy)

Gender: Male

Addresses Mailing Address: 74 Hanna Rd.

TORONTO, ON

M4G 3N1

CA

Phone Number: 6475054614

E-mail Address: [email protected]

Status In CanadaWhat is your status in Canada?: Citizen

If applicable, what is your date of landing: (dd/mm/yyyy)

Academic BackgroundDegree Type: Bachelor's Degree

University Name: Queen's University

Discipline Name: MINING & MINERAL PROCESSING

ENGINEERING

Program Name: QUEEN'S UNIVERSITY: Mining Eng'g: 1965-

Date Granted: 01/06/2012 (dd/mm/yyyy)

City: Kingston

Country: Canada

Referees

Version 1.0, May 1, 2007


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Relationship: Other

Other Type: Father

Name: Ray Camball

Address: 74 Hanna Rd.

License Number: 6530505

Good Character1. Have you ever been licensed by PEO? N

2. Have you ever applied to, but not been

licensed by, PEO?

N

3. Have you ever been licensed by anyprofessional engineering body in anotherprovince, territory or country?

N

4. Have you ever applied to, but not been

licensed by, any professional engineering bodyin another province, territory or country?

N

5. Have you ever been refused membership orhad a licence revoked or suspended by anotherengineering association/ordre?

N

6. Is there recorded on any register of anyprofessional engineering regulatory or licensing

body or equivalent organization any findingagainst you of professional misconduct orincompetence?

N

7. Have you ever been found guilty of anyoffence under a provincial/territorial or otherProfessional Engineers Act or its Regulations?

N

8. To your knowledge, are you currently beinginvestigated for any violation under a

provincial/territorial or other ProfessionalEngineers Act or its Regulations?

N

9. Do you have an alcohol or drug dependencythat renders you incapable of performing orfulfilling the essential duties or requirements ofa professional engineer?

N



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10. Do you suffer from any medical conditionthat renders you incapable of performing orfulfilling the essential duties or requirements ofa professional engineer?

N

11. Have you ever been found guilty of, or isthere any outstanding judgment against you in,any civil or criminal proceeding in Canada orabroad?

N

12. Has any finding of negligence been madeagainst you in any civil or criminal proceedingin Canada or abroad?

N



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Applicant's Declaration

I am applying for enrollment in the EIT Financial Credit Program ('FCP'). I understand that I must meet the FCPrequirements before I will be enrolled in the program. I also understand and agree that if I do meet the necessaryrequirements of the FCP Program that my application fee for a licence to practice professional engineering will bewaived and that at the same time I will be deemed to have applied for a licence to practice professional engineeringand that my FCP application will be used to apply for a licence to practice professional engineering. Finally, Iunderstand and agree that I will still be required to meet the licensing requirements set out in the ProfessionalEngineers Act (Ontario) and the Regulation there under before a licence to practice professional engineering will beissued to me.

I declare that the information in this application is true and complete. I understand that a false statement ormisrepresentation may disqualify me for a licence. I agree to file all required additional information if the informationcontained in my application changes between now and the date of my licensing as a professional engineer inOntario.

I hereby consent to and authorize Professional Engineers Ontario to share any information about me as anapplicant or practitioner with other associations and licensing bodies.

The information collected on this form is used for the purpose of regulating the practice of professional engineering.The immediate purpose for collecting this information is primarily to assist PEO is pursuing its regulatory activitiesand providing basic professional information to members of the public. For more information, see PEO's PrivacyPolicy at www.peo.on.ca, or contact PEO's Privacy Office at 416-224-1100.

Providing false information or misrepresentation of any kind may result in disqualification for a licence to practiseprofessional engineering in Ontario.

Signature:________________________ Date:___________________

Office Use Only

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