Free 09436ig.FH11 - Indiana

APPLICATION FOR REGISTRATION TO PRACTICE AS A LAND SURVEYOR
State Form 9436 (R8 / 10-06) Approved by State Board of Accounts, 2006

INDIANA STATE BOARD OF REGISTRATION FOR LAND SURVEYORS INDIANA PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3022 E-mail: [email protected] www.pla.IN.gov

* Your Social Security number is being requested by this state agency in accordance with
I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

APPLICATION NUMBER APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE LICENSE ISSUED (month, day, year)

PHOTO

DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY
Please check appropriate box:
Name of applicant (first, middle initial, last) Address (number and street) State Home telephone number ZIP code Business telephone number E-mail address Place of birth (city and state or country)

Comity

Exam APPLICANT INFORMATION
Have you ever had a name change?

Yes
City Social Security number

No

*

(

)

(

)

Date of birth (month, day, year) Name of firm Address (number and street, city, state, and ZIP code)

COLLEGE INFORMATION (Attach certified copy of transcripts from each school attended) Dates Attended Address of Institution (city, state, and ZIP code) Name of Institution From To

Graduation Degree Date

S.I.T. CERTIFICATIONS L.S. REGISTRATIONS

REGISTRATION BASIS (check)

WRITTEN EXAM HOURS

REGISTRATION VALID

S.I.T. L.S.

State

Registration Number

Date

Education & Experience

Comity

Exam

Survey Fund.

Survey Practice

Date

Date Expired

Reference forms are attached from five (5) persons listed below. Favorable replies must be received from at least three (3) registered land surveyors prior to action upon this application. References should have personal knowledge of your experience and/or ability to qualify. Providing references with up-to-date personal information will enable objective, confidential evaluations by the board. DO NOT submit the name of an Indiana board member as a reference. REFERENCES Name of Reference Reference LS Number Acquaintance, Employer, Associate, Etc. Current Address (number and street, city, state, and ZIP code)

PERSONAL BACKGROUND 1. Have you ever been convicted of: (A) an act which would constitute a ground for disciplinary sanction under IC 25-21.5 or (B) a felony that has a direct bearing on your ability to practice competently? 2. Have you been denied registration or has a registration ever been revoked or suspended? 3. Have you previously applied for and or taken the SIT/LS examination in Indiana or any other state? (If yes, please attach a statement identifying dates, states and any other pertinent information.) Yes Yes Yes No No No

INSTRUCTIONS: A photo must be attached to this application. List land surveying experience positions, beginning with the most recent. If necessary, attach extra sheets following the prescribed format. Please sign and date any extra sheets. For part-time employment, if less than 40 hours per week, list number of hours in space provided below. EXPERIENCE
Name of current employer Address (number and street) City, State, and ZIP code Duties Job title Number of years employed Name of Supervisor Period of employment

From___________ To __________ Full-time Part-time
Number of hours employed

Full-time Part-time

Name of employer Address (number and street) City, State, and ZIP code Duties

Job title Number of years employed Name of Supervisor

Period of employment

From___________ To __________ Full-time Part-time
Number of hours employed

Full-time Part-time

EXPERIENCE (continuation)
Name of employer Address (number and street) City, State, and ZIP code Duties Job title Number of years employed Name of Supervisor Period of employment

From___________ To __________ Full-time Part-time
Number of hours employed

Full-time Part-time

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for registration to practice as a land surveyor. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application and I hereby specifically release the Agency and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)