State Form 43741 - Application For Landscape Architect Reciprocal Registration - 2002
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4APPLICATION FOR LANDSCAPE ARCHITECT
INDIANA STATE BOARD OF
RECIPROCAL REGISTRATION
REGISTRATION FOR ARCHITECTS
State Form 43741 (R3 / 11-02)
302 West Washington Street, Room EO34
* Disclosure of your Social Security number is
Approved by State Board of Accounts, 2002
Indianapolis, IN 46204
MANDATORY in accordance with IC 4-1-8-1
Fee:
$100.00 with CLARB record
$400.00 without CLARB record
Attach a 2” x 3” recent photo of applicant.
Application number (office use only)
Name in full
Social Security number *
BUSINESS ADDRESS:
Name of firm
Telephone number
(
)
Address (number and street, city, state, ZIP code)
RESIDENCE ADDRESS:
Address (number and street, city, state, ZIP code)
Telephone number
(
)
ADDRESS FOR CORRESPONDENCE:
Citizenship
Birthdate
Place
Residence
Business
Birth
Naturalized
I hereby apply for Landscape Architect licensure by the following method:
Duration of residency in state (years, months):
Number
CLARB certificate number
State of registration
By Reciprocal Registration with CLARB.
By Reciprocal Registration without CLARB.
A. EDUCATIONAL BACKGROUND
File number
Name in full
DATES OF ATTENDANCE
PREPARATORY SCHOOLS, HIGH SCHOOLS
GRADES COMPLETE
(From-To)
DATES OF ATTENDANCE
COLLEGES, UNIVERSITIES, TECHNICAL SCHOOLS
GRADES COMPLETE
(From-To)
TRAVEL, CONTINUING EDUCATION, RESEARCH, PUBLICATIONS
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