Form State Form 46454 - Application For Registration To Practice Engineering
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1
2APPLICATION FOR
Application number
FOR OFFICE USE ONLY
REGISTRATION TO
C
N
PRACTICE ENGINEERING
O
U
Fees
N
M
Application for review of
State Form 46454 (R5 / 11-02)
examination . . . . $300.00
T
B
Approved by State Board of Accounts, 2002
R
E
Application for COMITY
Check appropriate box
O
R
registration to practice as
an engineer . . . . $500.00
L
Comity
Exam
This agency is requesting disclosure of personal information that is necessary to accomplish the statutory purpose of this board under IC 25-31. Disclosure of this information is
mandatory. Incomplete applications are subject to denial by the board. Upon completion, this form will be treated as a public record. *Your Social Security number is re-
quested by this agency in accordance with IC 4-1-8-1, which is mandatory, accessible by the Indiana Department of Revenue. Social Security number is not a public record. This
application will not be processed without it.
INSTRUCTIONS:
Type or print in ink. If necessary, attach extra sheets with each sheet dated and signed.
Appli-
l
l
cation must be accompanied by a recent photo.
Application must be accompanied by appropriate fee payable to
l
INDIANA PROFESSIONAL LICENSING AGENCY.
Designate preferred mailing address by placing an “X” in the
l
appropriate box.
Return application and all accompanying documents to:
l
Indiana Professional Licensing Agency
302 W. Washington St., Room E034
Indianapolis, IN 46204
1
APPLICANT INFORMATION
Name of applicant (first, MI, last)
Have you ever had a name change?
P H O T O
Yes
No
Address (number and street)
* Social Security number
Date of birth (month, day, year)
City, state, ZIP code
Name of firm
Place of birth
Address (number and street, city, state, ZIP code)
Home telephone number
Business telephone number
(
)
(
)
2
COLLEGE INFORMATION (Attach certified copy of transcripts from each school attended.)
Dates Attended
Graduation
Name of Institution
Address of Institution (city, state, ZIP code)
From
To
Degree
Date
E.I. CERTIFICATIONS
REGISTRATION
3
REGISTRATION BASIS (check)
WRITTEN EXAM HOURS
P.E. REGISTRATION
VALID
Registration
Education &
Engineer
Engineer
Date
E.I. / P.E.
State
Date
Comity
Exam
Date
Number
Experience
Fund
Practice
Expired
Reference forms are attached from 5 persons listed below. Favorable replies must be received from at least 3 registered professional engineers prior
to action upon this application. References should have personal knowledge of your experience and/or ability to qualify. Providing references with up-
to-date personal information will enable objective, confidential evaluations by the board. DO NOT submit the name of an Indiana board member as a
reference.
4
REFERENCES
Acquaintance,
Reference
Current Address
Name of Reference
Employer,
PE Number
(number and street, city, state, ZIP code)
Associate, Etc.
5
PERSONAL BACKGROUND
Have you ever been convicted of: (A) an act which would constitute a ground for disciplinary sanction under IC 25-31 or (B) a felony that has a direct bearing on your ability
to practice competently?
Yes
No
Have you ever been denied registration or has a registration ever been revoked or suspended?
Yes
No
Have you previously applied for and or taken the EI/PE examination in Indiana or any other state? If Yes, please attach a statement identifying dates, states and any other
pertinent information.
Yes
No
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