Form 4034 - Ncee Standard Verifi
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1Date (month, day, year)
NCEE STANDARD VERIFICATION - ENGINEER
File number
State Form 4034 (R5 / 6-93)
TO:
Indiana State Board of Registration
Name
for Professional Engineers
Indiana Government Center South
302 W. Washington St., Room E034
Indianapolis, IN 46204-2700
Street address
Telephone: (317) 232-2980
FROM:
City, state and ZIP code
Date of birth (month, day, year)
CERTIFICATE
DATE
VALID
The above named person was registered as:
UNTIL
NUMBER
ISSUED
Engineering Intern
Professional Engineer
HOURS
RESULTS
NCEE
EXAM DATE
Basis of Registration:
Written Examination
FE
PE
__________ Hrs PE
Oral Examination
EI accepted from:
PE accepted from:
Other
Remarks
B O A R D
S E A L
By:
Title
Date (month, day, year)
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