Free 46454.FH11 - Indiana

APPLICATION FOR REGISTRATION TO PRACTICE ENGINEERING
State Form 46454 (R6 / 7-06) Approved by State Board of Accounts, 2006

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

* 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. FOR OFFICE USE ONLY

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE OF ISSUE (month, day, year) DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS.
Please check one only:
Name of applicant (last, first, middle, maiden) Date of birth (month, day, year) Place of birth (city and state or country) Social Security number *

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

Engineering Intern

Professional Engineer APPLICANT INFORMATION

Address of applicant (number and street or rural route) City Telephone number (daytime) State E-mail address ZIP code

(
Name of firm

)

Address of firm (number and street) City Business telephone number State Website address ZIP code

(

)
EDUCATIONAL BACKGROUND NAME OF SCHOOL LOCATION OF SCHOOL DATES OF ATTENDANCE DEGREE EARNED

EXAMINATIONS FE EXAM TAKEN ON: ____________________________ STRUCTURAL I STRUCTURAL II DATE TAKEN: ____________________________ DATE TAKEN: ____________________________ PE EXAM TAKEN ON: _______________________________ STATE: ____________________________________ STATE: ____________________________________

REFERENCES NAME OF REFERENCES REFERENCE PE LICENSE NUMBER LIST ACQUAINTANCE, EMPLOYER, ASSOCIATE, ETC.

LIST ALL THE STATES IN WHICH YOU HAVE BEEN REGISTERED TO PRACTICE ANY REGULATED PROFESSION. STATE TYPE OF LICENSE, REGISTRATION, CERTIFICATION OR PERMIT NUMBER DATE ISSUED (month, day, year) CURRENT STATUS

EXPERIENCE
Name of current employer Address (number and street, city, state, and ZIP code) Duties Job title Name of supervisor Date of employment (month, day, year)

Full time Part time
Number of hours worked per week:

Name of previous employer Address (number and street, city, state, and ZIP code) Duties

Job title Name of supervisor

Date of employment (month, day, year)

Full time Part time
Number of hours worked per week:

ATTACHED ADDITIONAL SHEET IF NECESSARY.

PERSONAL BACKGROUND If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details; include the violation, location, date and disposition. Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a permit issued pursuant to this application. 1. Have you previously applied for or taken the EI/PE examination in Indiana or any other state? 2. Has disciplinary action ever been taken regarding any license, certifcate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit in any state (including Indiana)? 4. Are you now being, or have you ever been treated for drug or alcohol abuse? 5. Have you ever been convicted of, plead guilty or nolo contendere to any offense, misdemeanor or felony in any state? 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 signed (month, day, year)

Yes Yes Yes Yes Yes

No No No No No

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 their authorized representatives in connection with processing my application for registration to practice Engineering. 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. 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 signed (month, day, year)