Form 08-4398 - Application For Landscape Architect Registration By Examination Or Comity Page 5
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5ARCTIC REQUIREMENT (SEE 12 AAC 36.110(a))
Board-approved, arctic engineering, university-level course completed or in progress:
Date Completed:
College:
GENERAL INFORMATION QUESTIONS (AS 08.48.111)
Have you:
YES
NO
1.
had any felony convictions relating to the profession for which you are applying?..........................................
2.
had any professional society revocations?.......................................................................................................
3.
had any license actions or been denied renewal in another state or licensing jurisdiction? ............................
4.
had the right to practice before any state or federal agency denied, suspended, or revoked? .......................
5.
been found guilty of misconduct, dishonesty, fraud, incompetence, and/or gross negligence
in the practice of Landscape Architecture? ......................................................................................................
If the answer is “Yes” to any of the above questions, file a written explanation with your application.
All information provided with your response will be considered public information unless required to be kept confidential by state
or federal law.
RULES OF PROFESSIONAL CONDUCT
I hereby certify that I have read the Alaska Statutes Section 08.48 and Professional and Vocational Regulations Title 12,
Chapter 36, Alaska Administrative Code, and agree to abide by the rules of professional conduct as set forth therein.
APPLICANT SIGN HERE
Signature of Applicant
AFFIDAVIT
STATE OF
)
) ss.
Borough-County of
)
, being duly sworn, deposes and says: I am the applicant named in this
Name of Applicant
application, have read the contents thereof and, to the best of my knowledge and belief, the foregoing statements are true and
correct in every respect.
SUBSCRIBED AND SWORN TO before me this
day of
,
.
APPLICANT SIGN HERE
Signature of Applicant
(IN PRESENCE OF NOTARY)
NOTARY SIGN HERE
Signature of Notary Public
My Commission Expires:
08-4398 (Rev. 12/00)
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