State Form 44668 - Architect / Landscape Architect Verification Of Employment
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1PROFESSIONAL LICENSING AGENCY
ARCHITECT / LANDSCAPE ARCHITECT
Reset Form
INDIANA STATE BOARD OF
VERIFICATION OF EMPLOYMENT
REGISTRATION FOR ARCHITECTS
402 West Washington Street, Room W072
State Form 44668 (R3 / 8-06)
Indianapolis, IN 46204
T elephone: 317-234-3022
INSTRUCTIONS:
1.
Please type or print legibly.
E-mail: pla10@pla.IN.gov
2.
Please complete each numbered or lettered item. Incomplete forms will be returned.
3.
All applicants complete the top half of form. A qualified individual must complete the bottom portion of form.
4.
Please do not detach these forms.
APPLICANT COMPLETE
1. Indiana file number (For office use only)
2. Name of applicant
3. Current address (number and street, city, state, and ZIP code)
4. Was / Is employed by the firm:
5. Address of firm (number and street, city, state, and ZIP code)
9.
6. DATES OF
8. STATUS
7. LENGTH
INDICATE % OF TIME SPENT IN EACH PRACTICE CATEGORY
EMPLOYMENT
(Check one)
OF TIME
PART-TIME
(Less than
FULL-
TO
FROM
35 hours
TIME
per week)
3
MO DAY YR
HOURS/WEEK
MO DAY YR
10. Does the firm or an affiliate of the firm engage in construction?
Yes
No
11. Indicate services rendered by the firm:
Planning
Landscape Architect
Architecture
Interior Design / Contract Interiors
Other (explain on
Engineering
Construction Management
separate sheet)
Real Estate Development
12. Position of supervisor
Registered Architect
Landscape Architect
Planner
Registered Engineer
Interior Designer
Other (explain on separate sheet)
APPLICANT'S AUTHORIZATION AND RELEASE (This release must be signed before sending the form for completion below)
I hereby authorize the BOARD to make inquiries of the person listed below with respect to my background and character. I invite full and complete response to all inquiries.
I release said person from any and all claims, including claims for libel and slander, which may arise out of the communication of any information to the BOARD.
13. Signature of applicant
14. Date signed (month, day, year)
SPONSOR COMPLETE
This portion of the form must be completed by applicant's employer / supervisor at the referenced firm. Applicants must have this portion
completed by their sponsor at the referenced firm.
A. Are the dates of employment as shown in item 6 correct?
Yes
No
If No, please clarify:
B. Has the applicant worked under the direct supervision of the individual indicated in item 12 above?
Yes
No
If No, please clarify:
C. Are the experiences shown by the applicant in item 9 above correct?
Yes
No
If No, please clarify:
D. Indicate, to the best of your knowledge, the applicant's ability by placing an "X" in the appropriate spaces below. If unsatisfactory box is
checked for technical competence or professional conduct, please submit a letter of explanation with this form.
E. ON LATEST DATE OF EMPLOYMENT
F . ON DATE OF THIS REPL Y
SATIS-
UNSATIS-
SATIS-
UNSATIS-
EXCELLENT
MARGINAL
UNKNOWN
EXCELLENT
MARGINAL
UNKNOWN
FACTORY
FACTORY
FACTORY
FACTORY
TECHNICAL COMPETENCE
PROFESSIONAL CONDUCT
H.
Year(s)/state(s) of professional registration(s) (If none, indicate N/A)
G. Name of person completing this half of form
J. Name of current firm
I. Position in firm named in item 4 above (or relationship to firm)
Address of current firm (number and street, city, state, and ZIP code)
K. Position in current firm
L. Signature of sponsor
M. Date signed (month, day, year)
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