Landscape Architecture Form 4 - Report Of Professional Experience - The State Education Department
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1The University of the State of New York
Landscape Architect Form 4
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
REPORT OF PROFESSIONAL EXPERIENCE
APPLICANT INSTRUCTIONS
1.
Enter your name exactly as it appears on your Application for Licensure (Form 1).
2.
In item 5, provide a chronological list of your professional practice with the name and practice address of the licensed landscape architect(s) who will
attest to your practice. Be sure to sign and date item 6.
3.
Complete Section I of a corresponding Form 4A and send it to each licensed landscape architect listed in item 5.
1
2
Social Security Number
Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Your Full Name Exactly As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Professional Practice (Attach additional sheets if necessary)
5
Exact dates (mo./day/yr.)
Type of practice including name and address of licensed landscape architect (attach additional sheets if necessary).
From _____ / _____ / _____
To
_____ / _____ / _____
From _____ / _____ / _____
To
_____ / _____ / _____
From _____ / _____ / _____
To
_____ / _____ / _____
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I understand
6
that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure and may result in
criminal prosecution.
Applicant’s Signature
Date
Landscape Architect Form 4, (Rev. 02/06)
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