Fillable Form 44670 - Indiana Landscape Architect Reference

Form 44670 - Indiana Landscape Architect Reference - November 1999

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PLEASE TYPE OR LETTER NEATLY

INDIANA LANDSCAPE ARCHITECT REFERENCE

State Form 44670 (R / 11-99)

NOTE: Please complete each lettered or numbered item. Incomplete forms will be returned.

APPLICANT COMPLETE THIS SECTION

2. Name of applicant

1. Indiana file number

3. Name of reference

Address of reference (number and street, city, state, ZIP code)

4. Have you and the reference source attended architectural school together?

Yes

If Yes, give dates attended:

Name of school

5. Have you been employed in the same firm?

Yes

IF YES, PLEASE SUPPLY THE

7. SUBSEQUENT EMPLOYMENTS

6. FIRST EMPLOYMENT

FOLLOWING INFORMATION:

DATES: FROM - TO

NAME OF FIRM

LOCATION (city, state)

APPLICANT'S POSITION

REFERENCE'S POSITION

8. If answers to items 4 and 5 are "No", how is it that you know the reference?

APPLICANT'S AUTHORIZATION AND RELEASE (MUST BE SIGNED BEFORE SENDING FORM TO REFERENCE)

I hereby authorize the Board to make inquiries of the person listed as a reference with respect to my background and character. I invite full and complete

response to all inquiries. I release the reference from any and all claims, including claims for libel and slander, which may arise out of the communication of

any information to the Board.

9. Signature of applicant

10. Date signed

REFERENCE COMPLETE

A. Is the above information correct as stated?

Yes

No (if No, please explain)

(Use additional sheets to explain any special circumstances)

B. To the best of your knowledge, has the applicant ever practiced architecture as a principal?

If Yes, how long?

Yes

Years

Months

C. Please indicate, to your knowledge, the applicant's ability to practice architecture by placing an "X" in the appropriate spaces below. If "Unsatisfactory" box is checked for

"Technical Competence" or "Professional Conduct", please submit a letter of explanation with this form.

NOT QUALIFIED

EXCELLENT

SATISFACTORY

MARGINAL

UNSATISFACTORY

TO ANSWER

D. TECHNICAL COMPETENCE

E. PROFESSIONAL CONDUCT

Person supplying information above, please complete the following relative to yourself. Please type.

F. Name of person completing this reference:

G. Jurisdiction (state) of first architectural registration