Free 44738.PDF - Indiana

APPLICATION FOR INDIANA INTERN TRAINING AND EXPERIENCE RECORD
State Form 44738 (R2 / 7-99)

INDIANA STATE BOARD OF REGISTRATION FOR ARCHITECTS 302 West Washington Street, Room E034 Indianapolis, IN 46204 Telephone: (317) 232­2980

I hereby apply for the preparation of Indiana Intern Training and Experience Record in accordance with the standards and procedures established by the Indiana State Board of Registration for Architects, 804 IAC 1.1-7.
Indiana file number Name of applicant (first, middle, last)

Date (month, day, year) Name of firm

Social Security number

Your Social Security number is requested in accordance with IC 4-1-8.1. Disclosure is mandatory; the number is accessible by the Indiana Department of Revenue.

Business address (number and street, city, state, ZIP code)

Residence address (number and street, city, state, ZIP code)

Address for correspondence: Business Residence

Telephone number (include area code) ( )

Date of birth

If you have had a legal name change please attach a notarized document, attesting to this fact. A. EDUCATION HISTORY HIGH SCHOOL DATES OF ATTENDANCE (From-To) DATE GRADUATED

COLLEGES, UNIVERSITIES, TECHNICAL SCHOOLS

DATES OF ATTENDANCE (From-To) (Month, Year)

DEGREES OR CREDITS EARNED

B. PROFESSIONAL, PUBLIC AND COMMUNITY SERVICE

C. EXPERIENCE HISTORY Give the full name and complete address of employer. * Include periods of self-employment as well as military and non-architectural employment. Begin with first employer.
Name of employer

BOARD USE ONLY

Employer address (number and street, city, state, ZIP code)

DATE OF EMPLOYMENT *

LENGTH OF TIME ** PARTTIME (Less than 35 hours per week)

STATUS (Check appropriate category)

TYPE OF FIRM (Check appropriate category)

FROM

TO

FULLTIME

MO DAY YR

MO DAY YR

3

HOURS/WEEK

* List each period of continuous employment separately even if for the same employer. If any of the conditions of employment (i.e. full-time / part-time status, type of firm) change, list each period separately. ** If part-time work is noted, state average number of hours per week. *** If "other" kinds of work are noted, describe on separate page.

Page 1

C. EXPERIENCE HISTORY (Continued)
Name of employer

BOARD USE ONLY

Employer address (number and street, city, state, ZIP code)

DATE OF EMPLOYMENT *

LENGTH OF TIME ** PARTTIME (Less than 35 hours per week)

STATUS (Check appropriate category)

TYPE OF FIRM (Check appropriate category)

FROM

TO

FULLTIME

MO DAY YR

MO DAY YR

3

HOURS/WEEK

Name of employer

BOARD USE ONLY

Employer address (number and street, city, state, ZIP code)

DATE OF EMPLOYMENT *

LENGTH OF TIME ** PARTTIME (Less than 35 hours per week)

STATUS (Check appropriate category)

TYPE OF FIRM (Check appropriate category)

FROM

TO

FULLTIME

MO DAY YR

MO DAY YR

3

HOURS/WEEK

Name of employer

BOARD USE ONLY

Employer address (number and street, city, state, ZIP code)

DATE OF EMPLOYMENT *

LENGTH OF TIME ** PARTTIME (Less than 35 hours per week)

STATUS (Check appropriate category)

TYPE OF FIRM (Check appropriate category)

FROM

TO

FULLTIME

MO DAY YR

MO DAY YR

3

HOURS/WEEK

* List each period of continuous employment separately even if for the same employer. If any of the conditions of employment (i.e. full-time / part-time status, type of firm) change, list each period separately. ** If part-time work is noted, state average number of hours per week. *** If "other" kinds of work are noted, describe on separate page.

D. ARCHITECT REFERENCES
Give the name and address of three (3) architects who are currently personally acquainted with your professional experience, abilities and professional activities. Present employers, fellow employees, present partners or relatives are not to be used for these references.
1. Name of reference

Address (number and street, city, state, ZIP code) 2. Name of reference

Address (number and street, city, state, ZIP code)

3. Name of reference

Address (number and street, city, state, ZIP code)

Page 2

E. AFFIDAVIT AND NOTARIZATION "The applicant acknowledges that the Indiana State Board of Registration for Architects (the Board), will compile and evaluate a record with respect to all aspects of the applicant's career. The applicant agrees to provide any additional information in connection with the investigation as may be required by the Board." I have have not been convicted of any felony or misdemeanor * (If this item is answered in the affirmative, attach a separate page that describes such conviction, stating the nature of each crime, whether or not each crime was a misdemeanor or a felony, the date of conviction, the cause number and the jurisdiction where the conviction was issued.) The undersigned, being duly sworn upon oath, deposes and says that the undersigned is the person making the foregoing statements and that they are made in good faith and are true in every respect.
Signature of applicant

State of : County of:

Sworn by the deponent _____________________________________________________________________________________________ , known to me, at ___________________________________________________________________________________________________ , ____________________________________________________________________________________________________________ on the _______________________________________________day of ________________________________________________ , _________ . Before me, __________________________________________________________________________________________________________
(Notary Pubilc, printed name)

___________________________________________________________________________________________________________________
(Notary Public, signature)

Notary expires:

SEAL

Resident county of:

* This information is solicited under the authority of Indiana Code 25-4-1-7. Applicant is not required by law to reveal every conviction but only those which are either (1) a felony that has a direct bearing on the applicant's ability to practice competently or (2) an act which would constitute a ground for disciplinary sanction under Indiana Code 25-4-1-15.1. Applicants who question whether a particular conviction must be reported by law should immediately contact the Professional Licensing Agency, Board of Registration for Architects. F. PHOTOGRAPH OF APPLICANT (2" X 3")

Page 3