Form 9436 - Application For Registration To Practice As A Land Surveyor (Page 2 of 2) in pdf

Form 9436 - Application For Registration To Practice As A Land Surveyor Page 2

INSTRUCTIONS: A photo must be attached to this application. List land surveying 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.

EXPERIENCE

Name of current employer

Job title

Period of employment

From___________ To __________

Number of years

Number of hours

Address (number and street)

Full-time

employed

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

employed

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

employed

Part-time

City, State, ZIP code

Name of Supervisor

Duties

NOTARY CERTIFICATE

STATE OF

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SS:

COUNTY OF

On ____________________ day of ___________________ , ________ , I, ________________________________________________________ ,

a resident of __________________________, certify that I have read the text of the Indiana Registration Act for Land Surveyors 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 as references, whether they may be an individual, a company, or an institution, to furnish the State Board information concerning my

education, experience, character and suitability for practicing land surveying. 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)

Date commission expires

County of residence