Form State Form 46454 - Application For Registration To Practice Engineering Page 2
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2INSTRUCTIONS: A photo must be attached to this application. List all engineering experience positions, beginning with the most recent. If necessary, attach
extra sheets following the prescribed format. Please sign and date any extra sheets. For part-time employment, if less than 40 hours per week, list number of
hours in space provided below.
6
EXPERIENCE
Name of current employer
Job title
Period of employment
From __________ To _________
Address (number and street)
Number of years
Number of hours
Full-time
Full-time
employed
employed
Part-time
Part-time
City, state, ZIP code
Name of supervisor
Duties
Name of employer
Job title
Period of employment
From __________ To _________
Address (number and street)
Number of years
Number of hours
Full-time
Full-time
employed
employed
Part-time
Part-time
City, state, ZIP code
Name of supervisor
Duties
Name of employer
Job title
Period of employment
From __________ To _________
Address (number and street)
Number of years
Number of hours
Full-time
Full-time
employed
employed
Part-time
Part-time
City, state, ZIP code
Name of supervisor
Duties
7
NOTARY CERTIFICATE
STATE OF
}
SS:
COUNTY OF
On this _________ day of __________________________________, ________, I, ________________________________________________,
a resident of _______________________________ certify that I have read the text of the Indiana Registration Act for Professional Engineers as
amended, covering the requirements to be met by an applicant, and Rules of the Board, that the statements contained in this application are true
and correct to the best of my knowledge and that if granted registration I will abide by the Indiana Registration Act and Rules of the Board. I
authorize those whom I have given references, whether they may be an individual, a company, or an institution, to furnish the State Board infor-
mation concerning my education, experience, character and suitability for practicing engineering. I agree to release and hold harmless any
individual, company, or institution and any person or persons connected therewith from liability imposed by law in furnishing such information.
Signature of applicant
Signature of Notary Public
Printed or typed name of applicant
Printed or typed name of Notary Public
Date subscribed and sworn to(Notary Public)
County of residence
Date commission expires
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