Professional Engineer Reference Form Page 3
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310. From your personal knowledge, please list the type of work the applicant has performed and provide the details of
his or her responsibilities.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
11. From your personal knowledge, for how many years has the applicant been engaged in engineering? __________
12. Please refer to the attached “Description of Experience.” How much of the time noted in question 11 has the
applicant been involved in original design work under the direct supervision of a professional engineer?
_____________ years.
13. Do you consider that the applicant has reached a professional level in his or her work?
__________________________________________________________________________________________
__________________________________________________________________________________________
14. The Board would appreciate any additional information that you may wish to provide. _____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
15. If you have any reason to believe that licensure of the applicant should be withheld at this time, please comment
below.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
16. If you are not a professional engineer, what is your business or profession? ______________________________
__________________________________________________________________________________________
17. If you are a professional engineer, please provide your license number:________________________, _________
License number State of licensure
Your signature on this reference form indicates that you verify that the time and value of the applicant’s experience as
outlined on the attached “Description of Experience” is accurate to the best of your knowledge as of the date of your
signature.
__________________________________________________________ __________________________
Signature Date
_______________________________________
Telephone Number (include area code)
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