State Form 1576 - Application For Architect Reciprocal Registration

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APPLICATION FOR ARCHITECT RECIPROCAL REGISTRATION
Indiana Professional Licensing Agency
Board of Registration for Architects
302 W. Washington St., Rm. E034
State Form 1576 (R7 / 11-02)
Indianapolis, IN 46204-2700
Approved by State Board of Accounts, 2002
$100.00 With NCARB record
Fee:
$400.00 Without NCARB record
All fees are nonrefundable and nontransferable
Attach a 2" x 3" recent photo of applicant
File number (office use only)
* This agency is requesting the disclosure of your Social Security Number in accordance with IC 4-1-8-1. Disclosure is mandatory;
this record cannot be processed without it. The number will be made available to the Indiana Department of Revenue.
Date (month, day, year)
Applicant's name in full
Social Security number *
Business Address
Name of firm
Address (number and street)
City
State
ZIP code
Residence Address
Address (number and street)
City
State
ZIP code
Address for Correspondence
Telephone number
Residence
Business
(
)
Date of birth (month, day, year)
Citizenship
I hereby apply for registration and license to practice architecture by the following method:
By Reciprocal Registration with NCARB
NCARB certificate Number ________________________
State of Registration ____________________________
By Reciprocal Registration without NCARB
STATE(S) OF REGISTRATION
EXPIRATION DATE
REGISTRATION NUMBER
(see reverse side)

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