Looking for a Indiana Legal Forms And Templates? Download it for free!

State Form 9101 - Indiana Application For Certification Of Engineering Intern - 2002 Page 2

INSTRUCTIONS: A photo must be attached to this application. List all engineering 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

Job title

Period of employment

From___________ To __________

No. of years

No. of hours

Address (number and street)

Full-time

employed

Part-time

City, state, ZIP code

Name of supervisor

Duties

Name of current employer

Job title

Period of employment

From___________ To __________

No. of years

No. of hours

Address (number and street)

Full-time

employed

Part-time

City, state, ZIP code

Name of supervisor

Duties

Job title

Period of employment

Name of current employer

From___________ To __________

No. of hours

No. of years

Address (number and street)

Full-time

employed

Part-time

Name of supervisor

City, state, ZIP code

Duties

NOTARY CERTIFICATE

}

STATE OF

SS:

COUNTY OF

On ____________________ day of ___________________ , 20 ______ , I, ________________________________________________________ ,

a resident of __________________________ certify that I have read the text of the Indiana Registration Act for Professional Engineers as amended,

covering the requirements to be met by an applicant, and Rules of the board, that the statements contained in this application are true and correct to

the best of my knowledge and that if granted registration I will abide by the Indiana Registration Act and Rules of the board. I authorize those whom

I have given as references, whether they may be an individual, a company, or an institution, to furnish the State Board information concerning my

education, experience, character and suitability for practicing Engineering. I agree to release and hold harmless any individual, company, or institution

and any person or persons connected therewith from liability imposed by law in furnishing such information.

Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public

Date subscribed and sworn to (Notary Public)

County of residence

Date commission expires