Free 45691.PDF - Indiana

APPLICATION FOR ARCHITECT EXAMINATION
State Form 45691 (R5 / 12-02) Approved by State Board of Accounts, 2002

FEE: $50.00

All fees are nonrefundable and nontransferable

Indiana State Board of Registration for Architects and Landscape Architects 302 W. Washington St. Rm. E034 Indianapolis, Indiana 46204 (317) 232-2980 www.in.gov/pla
Application file number

NCARB / IDP file number Name of applicant (first, middle, last)

Indiana Intern file number

*Your Social Security number is requested in accordance with IC 4-1-8.1, which is mandatory, and is accessible by the Indiana Department of Revenue. BUSINESS ADDRESS
Name of firm

*Social Security number

Telephone number

(
Address of firm (number and street, city, state, ZIP code)

)

RESIDENCE ADDRESS
Address (number and street, city, state, ZIP code) Telephone number Birthdate (month, day, year) Business

Address for correspondence Residence

(

)

I hereby make application to sit for the ________________________________ architect examination.
Date

NCARB / IDP APPLICANT Transmittal of my NCARB / IDP Council Record to the Indiana State Board of Registration for Architects was requested ______________________ . File number: ____________ INDIANA INTERN APPLICANT Application for Indiana Intern Training and Experience Record was established __________________________________________ .
Signature of applicant Date signed (month, day, year)

A recent Photo must accompany this application.

3" x 3" Recent Photo

PLEASE COMPLETE THE FOLLOWING SECTIONS AND RETURN TO IPLA a. Have you ever been denied registration? b. Has your license ever been suspended or revoked? c. Have you surrendered or allowed your registration to lapse in any jurisdiction due to an action pending or threatened? d. Has a court or registration board ever found that you have violated the law in the conduct of your architectural practice or that you have engaged in conduct involving the wanton disregard for the rights of others? e. Have you entered into a consent or other agreement with any registration board in connection with disciplinary action? Yes Yes Yes No No No

Yes Yes

No No

If you have answered yes to any of the above questions, provide dates and details of the situation in the space below (include the result of any appeals)

AFFIDAVIT AND NOTARIZATION The applicant acknowledges that the Indiana Professional Licensing Agency will compile and evaluate a record with respect to all aspects of the applicant's career. The applicant agrees to provide any additional information in connection with the investigation as may be required by us. The applicant acknowledges that any statements provided will be available to the applicant. The applicant hereby authorizes the IPLA to transmit the applicant's record and all other pertinent information obtained in the course of its investigation to Architectural Registration Boards of States, Provincial Registars or other political subdivisions registering architects. In consideration of the services to be rendered by the IPLA, the applicant hereby releases, discharges and exonerates the Indiana Professional Licensing Agency, its officers, directors and agents from any and all liability or every nature and kind arising out of the transmission of information concerning the application. The undersigned, being duly sworn, upon oath deposes and says that he / she is the person making the foregoing statements, and that they are made in good faith and are true in every respect.
Signature of applicant Date (month, day, year)

STATE / PROVINCE OR COUNTRY OF: COUNTY OF:
Subscribed and sworn by the deponent ___________________________________________________________________________________________ before me, at _______________________________________________________________________________________________________________ on ______________________ day of ___________________________, 20_______.

By _______________________________________________________

N O TA R Y SEAL