Architecture Form 4 - Applicant Experience Verification
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1
2The University of the State of New York
Architect
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 4
Division of Professional Licensing Services
Applicant Experience Record
Instructions
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and
date item 8.
2.
Ask your supervisor to complete Section II and forward the entire form directly to the Office of the Professions at the address at the end
of this form. If additional copies are needed, you may photocopy this form.
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
4.
Print Name Exactly As You Wish It To Appear On Your License
6.
5
Telephone/E-Mail Address
Last
Daytime phone
First
Middle
Area Code
Phone
E-mail Address
(please print clearly)
4
5.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
If we may discuss your licensure
using this e-mail address, please
Line 3
check this box.
City
State
Zip Code
Country/
Province
6
6.
You were/am employed by the firm of: ______________________________________________________________________________
7
7.
Professional Work Experience Record
While employed, you rendered the following services (check all that apply):
Architecture
Landscape Architecture Coordination
Construction
Other (Explain)*
Planning
Engineering Coordination
Construction Management
Dates of Employment
Length of Time
Check Appropriate Experiences
In the Posting of
General Practice of Architecture
Collateral Activity
Part-Time
From
To
Full Time
(Less than 35 hours
per week)
mo
yr
mo
yr
* Explain how this experience was equivalent to that obtained in an architect's office. Public service includes experience gained in federal, state or local government departments
and/or semi-public agencies. "Other" includes Professional Engineer, Interior Design, Landscape Architecture, General Contractor, etc.
Architect Form 4, Page 1 of 2 (Rev. 10/08)
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