State Form 1576 - Application For Architect Reciprocal Registration Page 2

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*PLEASE COMPLETE THE FOLLOWING SECTIONS AND RETURN TO IPLA

Yes

a. Have you ever been denied registration?

Yes

b. Has your license ever been suspended or revoked?

c. Have you surrendered or allowed your registration to lapse

Yes

in any jurisdiction due to an action pending or threatened?

d. Has a court or registration board ever found that you have

violated the law in the conduct of your architectural practice

or that you have engaged in conduct involving the wanton

disregard for the rights of others?

Yes

e. Have you entered into a consent or other agreement with

Yes

any registration board in connection with disciplinary action?

If you have answered yes to any of the above questions, provide dates and details of the situation in the space below (include the result of any appeals)

AFFIDAVIT AND NOTARIZATION

The applicant acknowledges that the Indiana Professional Licensing Agency will compile and evaluate a record with respect to all aspects of the applicant's

career. The applicant agrees to provide any additional information in connection with the investigation as may be required by us.

The applicant acknowledges that any statements provided will be available to the applicant. The applicant hereby authorizes the IPLA to transmit the

applicant's record and all other pertinent information obtained in the course of its investigation to Architectural Registration Boards of States, Provincial

Registars or other political subdivisions registering architects.

In consideration of the services to be rendered by the IPLA, the applicant hereby releases, discharges and exonerates the Indiana Professional Licensing

Agency, its officers, directors and agents from any and all liability or every nature and kind arising out of the transmission of information concerning the

application.

The undersigned, being duly sworn, upon oath deposes and says that he / she is the person making the foregoing statements, and that they are made in

good faith and are true in every respect.

Date (month, day, year)

Signature of applicant

STATE / PROVINCE OR COUNTRY OF:

COUNTY OF:

Subscribed and sworn by the deponent ___________________________________________________________________________________________

before me, at _______________________________________________________________________________________________________________

on ______________________ day of ___________________________, _______________.

By _______________________________________________________

N O T A R Y

A T T A C H

S E A L

P H O T O

* This information is solicited under the authority of Indiana Code 25-4-1-7. Applicant is not required by law to reveal every conviction but only those which are either (1) a felony

that has a direct bearing on the applicant's ability to practice competently or (2) an act which would constitute a ground for disciplinary sanction under Indiana Code 25-4-1-15.1.

Applicants who question whether a particular conviction must be reported by law should immediately contact the Professional Licensing Agency, Board of Registration for Architects.