Free 52780.pdf - Indiana

APPLICATION FOR FEDERAL PROFESSIONAL QUALIFICATIONS DOCUMENTATION FOR ARCHITECTURE
State Form 52780 (8-06)

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF HISTORIC PRESERVATION AND ARCHAEOLOGY 402 West Washington Street, Room W274 Indianapolis, Indiana 46204-2739 Telephone: (317) 232-1646 Fax: (317) 232-0693 E-mail: [email protected]

Individual Name: Company/University Name: Address: City: Telephone: Email: State: Fax Number: Website: Zip Code:

We are requesting the following information to document that you meet or exceed the Federal requirements stated in "Archaeology and Historic Preservation: Secretary of the Interior's Standards and Guidelines," Federal Register, Vol. 48, No. 190-September 29, 1983, Pt. IV. The minimum professional qualifications for architecture are a professional degree in architecture plus at least two years of full-time experience in architecture; or a state license to practice architecture. A. List your professional degree in architecture. institution. Include the degree, year, and

____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ B. List your experience in architecture, including employers, dates employed, title, nature of work, and length of experience converted to full-time months. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ C. State license to practice architecture? ___ Yes ___ No

State(s): _____________________________________________________________ License Number(s):____________________________________________________

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Effective dates of license: _______________________________________________

ALL APPLICANTS

A.

Attach a statement with any other information or explanations which you would like to have considered. Attach a current resume or curriculum vitae to this completed form. If you are a licensed architect, please provide a copy of your current license. The information submitted on this form and with the attachments to this form is accurate to the best of my knowledge. The information submitted on this form and with the attachments to this form is accurate to the best of my knowledge. I understand that inclusion in the list does not constitute endorsement or guarantee of any individual consultant, any contracting firm or any consultant's work or work products. I also understand that it is my responsibility to inform the DHPA of any changes that may become necessary to the information provided. Name: ____________________________________ Signature: ____________________________________ Date: ____________________________________

B. C. D.

Submission: 1. Submit your documentation to the Indiana Division of Historic Preservation and Archaeology, 402 W. Washington Street, Room W274, Indianapolis, Indiana 462042739. The Indiana Division of Historic Preservation and Archaeology will review your documentation to determine if your qualifications meet the standards established by the National Park Service. If we determine your qualifications meet the standards, you will be added to the roster. If we find that you do not meet the standards, you will receive an explanation of why your qualifications do not meet the standards. Contact the Indiana Division of Historic Preservation and Archaeology with questions at the address above, by calling Karie Brudis at (317) 232-1646, or by E-mail: [email protected].

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