State Form 9101 - Indiana Application For Certification Of Engineering Intern - 2002

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APPLICATION FOR CERTIFICATION
FOR OFFICE USE ONLY
OF ENGINEERING INTERN
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State Form 9101 (R6 / 4-02)
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Approved by State Board of Accounts, 2002
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DO NOT WRITE IN THIS SPACE (Incomplete applications will not be accepted.)
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Application number
Date received
Certification number
Date received
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This agency is requesting disclosure of personal information that is necessary to accomplish the statutory purpose of this board under I.C. 25-31. Disclosure of this information is
mandatory. Incomplete applications are subject to denial by the board. Upon completion, this form will be treated as a public record. * Your social security number is requested by
this agency in accordance with I. C. 4-1-8.1, disclosure is mandatory; this record cannot be processed without it.
SENIORS enrolled in an ABET engineering curriculum shall complete sections 1,2,4 & 6 only. Other applicants shall complete sections 1 through 6.
INSTRUCTIONS: Please type or print in ink. If necessary, attach extra sheets with each dated and signed. This application must be accompanied by a photo.
Enclose an examination and enrollment fee of $100.00 (One-Hundred dollars), payable to Engineer's Registration Board. Return application and all accompanying
documents to:
Indiana Professional Licensing Agency
Indiana Government Center South
302 W. Washington Street, Room 034
Indianapolis, IN 46204
Designate preferred mailing address by placing an "x" in the appropriate box.
1
APPLICANT INFORMATION
Have you ever had a name change?
Name of applicant (first, mi, last)
* Social Security number
Yes
No
Birth place
Birth date
Address (number and street)
City, state, ZIP code
Home telephone number
(
)
Name of firm
Address (number and street)
Business telephone number
(
)
City, state, ZIP code
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COLLEGE INFORMATION (Attach certified copy of transcripts from each school attended.)
DATES ATTENDED
GRADUATION
ADDRESS OF INSTITUTION (City, state, ZIP code)
NAME OF INSTITUTION
From
Degree
Date
To
Reference forms are attached from 3 persons listed below. 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.
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REFERENCES
REFERENCE
ACQUAINTANCE,
NAME OF REFERENCE
CURRENT ADDRESS
PE
EMPLOYER,
(Minimum of 3 required)
(Number and street, city, state, ZIP code)
NUMBER
ASSOCIATE, ETC.
PERSONAL BACKGROUND
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Have you ever been denied certification or has a certificate ever been revoked/suspended?
Yes
No
Have you been convicted of: (A) an act which would constitute a ground for disciplinary sanction under I.C. 25-31 or (B) a felony that has a direct bearing on your ability to practice
competently?
Yes
No
Have you previously applied for and or taken the EI examination in Indiana or any other state? If yes, please attach a statement identifying dates, states and any other pertinent
information.
Yes
No
(Continued on the reverse side)

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