Professional Engineering - Application For Licensure And First Registration - The University Of The State Of New York The State Education Department - 2011 Page 2

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13
In the spaces below, give an accurate record of your educational preparation. Be sure to complete items A-D for each school. Please print. Attach additional sheets if necessary.
C. ATTENDANCE
B. NUMBER OF
D. TITLE OF DIPLOMA OR
YEARS
A. NAME OF SCHOOLS ATTENDED AND LOCATIONS
DEGREE OBTAINED*
ATTENDED
Entrance Date
Leaving Date
Elementary or Primary School (Complete if educated outside the United States)
A
D
C
B
______________________________________________________________________________________________________________
School Name
_____ / _____
_____ / _____
________________________________________________________________________
____________________________________
mo
yr
mo
yr
City
State/Country
High School or Secondary School (Complete if educated outside the United States)
D
C
B
A
______________________________________________________________________________________________________________
_____ / ____C_
_____ / _____
School Name
mo
yr
mo
yr
________________________________________________________________________
____________________________________
City
State/Country
College or University-level School(s)
Office
*Note: If your professional school was located outside the U.S., and
use
you have a copy of your degree/diploma in the original language,
only
attach a copy to this form.
_________________________________________________________________________________________________________
School Name
________________________________________________________________________
____________________________________
_____ / _____
_____ / _____
City
State/Country
mo
yr
mo
yr
A
C
B
D
_________________________________________________________________________________________________________
School Name
________________________________________________________________________
____________________________________
_____ / _____
_____ / _____
City
State/Country
mo
yr
mo
yr
_________________________________________________________________________________________________________
School Name
________________________________________________________________________
____________________________________
_____ / _____
_____ / _____
City
State/Country
mo
yr
mo
yr
14
Are you requesting a year of experience credit for an approved graduate degree program in engineering?
YES
NO
(If yes, Form 2 must be submitted with a transcript from your graduate degree program.)
Total
15
Do you now hold, or have you ever held, a license or certificate to practice any profession in any jurisdiction?
(If so, list below and attach other pages as needed.)
________________________________________________________ _____________________________ _______________________________ Expiration date
______ / _______ / _______
Profession
License Number
Jurisdiction
Mo.
Day
Yr.
________________________________________________________ _____________________________ _______________________________ Expiration date
______ / _______ / _______
Profession
License Number
Jurisdiction
Mo.
Day
Yr.
16
Do you intend to engage in interim practice while your application is under consideration?
YES
NO
(If yes, you must submit a Form 5)
Professional Engineering Form 1, Page 2 of 4, Rev. 4/11

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