Architecture Form 4 - Applicant Experience Verification Page 2
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1
27.
8
Attestation
I hereby certify that the work experience described on this form and the time claimed for that experience are true and accurate.
_________________________________________________________________________
_______________________________
Applicant's signature
Date
Section II: Verification of Experience
Instructions to Supervisor: To uphold the purposes of the licensing law and safeguard life, health and property, the State Board for
Architecture evaluates the level and character of each applicant's practical experience in architectural work.
1.
Please complete Section II. The ratings and comments you provide below will help the Board evaluate the applicant's work, ability,
character, and reputation.
2.
Please respond promptly. Return this form directly to the Office of the Professions at the address at the end of this form. This
form will not be accepted if returned by the applicant.
1
Are the dates of employment as show in item 6 on the reverse side correct?
Yes
No
(If no, please clarify.)
2
Is the experience record completed by the applicant for the dates of employment in item 6 on the
reverse side correct? (If no, please clarify)
Yes
No
3
Please indicate to the best of your knowledge the applicant's potential to practice architecture by placing an "X" in the appropriate
spaces below. If you check the "unsatisfactory" box for "experience" or "conduct," please submit a letter of explanation with this form.
On Last Date of Employment
On Date of This Reply
Not
Not
Unsatis-
Unsatis-
Excellent
Satisfactory
Marginal
Qualified to
Excellent
Satisfactory
Marginal
Qualified to
factory
factory
Answer
Answer
Education
Practical Experience
Professional Conduct
Attestation
I have read the applicant's Professional Work Experience Record. I hereby certify that I am knowledgeable about, and qualified to attest to,
the applicant's work and architectural ability and that, except as otherwise noted on this form, or in attached correspondence, the work
experience described by the applicant and the time claimed for it are true and accurate.
Signature of endorser: _____________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print name: ______________________________________________________________________
Title: ____________________________________________________________________________
Place
State(s)/Date(s) of registration: _______________________________________________________
Stamp or Seal
Here
Name of firm: _____________________________________________________________________
Telephone: ___________________________________ Fax: _______________________________
E-mail: __________________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Architecture Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Architect Form 4, Page 2 of 2 (Rev. 10/08)
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