Free 53138.pdf - Indiana

APPLICATION FOR FEDERAL PROFESSIONAL QUALIFICATIONS DOCUMENTATION FOR HISTORIC ARCHITECTURE
State Form 53138 (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 historic architecture are a professional degree in architecture or a state license to practice architecture, plus one of the following: 1. At least one year of graduate study in architectural preservation, American architectural history, preservation planning, or a closely related field; or 2. At least one year of full-time professional experience on historic preservation projects. Such graduate study or experience shall include detailed investigation of historic structures, preparation of historic structures research reports, and preparation of plans and specifications for preservation projects. A. List your professional degree in architecture. Include the degree, year, institution and area of specialization. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ State license to practice architecture? ___ Yes ___ No State(s):_____________________________________________________________ License Number(s):____________________________________________________

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Effective dates of license:_______________________________________________ C. List any graduate study in architectural preservation, American architectural history, preservation planning or a closely related field. Include length of study, institution, and field of specialization. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ D. List any full-time professional experience on preservation, rehabilitation, or restoration projects. Experience on preservation, rehabilitation, or restoration projects shall include detailed investigation of historic structures, preparation of historic structures research reports and preparation of plans and specifications for preservation projects. Include employer, dates employed, project, nature of work, and length of experience converted to full-time months. (Attach additional pages as necessary.) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

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ALL APPLICANTS

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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. 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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