Form 44738-Application For Indiana Intern Training And Experience Record Jule 1999

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INDIANA STATE BOARD OF REGISTRATION

APPLICATION FOR INDIANA INTERN TRAINING

FOR ARCHITECTS

AND EXPERIENCE RECORD

302 West Washington Street, Room E034

State Form 44738 (R2 / 7-99)

Indianapolis, IN 46204

Telephone: (317) 232–2980

I hereby apply for the preparation of Indiana Intern Training and Experience Record in accordance with the standards and procedures established by the

Indiana State Board of Registration for Architects, 804 IAC 1.1-7.

Name of applicant (first, middle, last)

Indiana file number

Social Security number

Date (month, day, year)

Your Social Security number is requested in accordance with IC 4-1-8.1. Disclosure is

mandatory; the number is accessible by the Indiana Department of Revenue.

Name of firm

Business address (number and street, city, state, ZIP code)

Residence address (number and street, city, state, ZIP code)

Address for correspondence:

Telephone number (include area code)

Date of birth

(

)

Business

Residence

If you have had a legal name change please attach a notarized document, attesting to this fact.

A. EDUCATION HISTORY

DATES OF ATTENDANCE

HIGH SCHOOL

DATE GRADUATED

(From-To)

DATES OF ATTENDANCE

DEGREES OR CREDITS

COLLEGES, UNIVERSITIES, TECHNICAL SCHOOLS

(From-To) (Month, Year)

EARNED

B. PROFESSIONAL, PUBLIC AND COMMUNITY SERVICE

C. EXPERIENCE HISTORY

Give the full name and complete address of employer. * Include periods of self-employment as well as military and non-architectural employment. Begin

with first employer.

Name of employer

BOARD USE

ONLY

Employer address (number and street, city, state, ZIP code)

STATUS

TYPE OF FIRM

DATE OF EMPLOYMENT *

LENGTH OF TIME

(Check appropriate category)

PARTTIME

(Less than

35 hours

FULL-

FROM

per week)

TIME

HOURS/WEEK

MO DAY YR

* List each period of continuous employment separately even if for the same employer. If any of the conditions of employment (i.e. full-time / part-time status, type of firm) change, list each period

separately.

** If part-time work is noted, state average number of hours per week.

*** If "other" kinds of work are noted, describe on separate page.

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