Free 50153.PDF - Indiana

APPLICATION FOR LANDSCAPE ARCHITECT EXAMINATION
State Form 50153 (R/11-02) Approved by State Board of Accounts, 2002

FEE: $50.00
All fees are nonrefundable and nontransferable.
CLARB file number Name of applicant (first, middle, last)

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. Washington St., Room E034 Indianapolis, IN 46204 (317) 232-2980 www.state.in.us/pla

Application file number (for office use only)

* Your Social Security number is requested in accordance with IC 4-1-8-1. Disclosure is mandatory, this record cannot be processed without it.
Name of firm Address of firm (number and street, city, state, ZIP code)

Social Security number *

BUSINESS ADDRESS
Telephone number

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

Telephone number

Address for correspondence

Birthdate (month, day, year)

Residence

Business

I hereby make application to sit for the _______________________________ landscape architect examination.
Date

CLARB APPLICANT Transmittal of my CLARB Council record to the Board of Registration for Architects and Landscape Architects requested on this date: ___________________________________ .
Signature of applicant Date signed (month, day, year)

Attach a recent 3" x 3" photograph to this application in the box provided below.

(Application continued on the reverse side.)

PLEASE COMPLETE THE FOLLOWING

1) Have you ever been denied registration? 2) Has your license ever been suspended or revoked? 3) Have you surrendered or allowed your registration to lapse in any jurisdiction due to an action pending or threatened? 4) Has a court or registration board ever found that you have violated the law in the conduct of your landscape architectural practice or that you have engaged in conduct involving the wanton disregard for the rights of others? 5) Have you ever entered into a consent or other agreement with any registration board in connection with disciplinary action?

Yes Yes Yes Yes Yes

No No No No No

If you have answered yes to any of the above questions, provide dates and details of the situation in the space below. (include the result of any appeals)

AFFIDAVIT AND NOTARIZATION

The applicant acknowledges that the Indiana Professional Licensing Agency 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 us. The applicant acknowledges that any statements provided will be available to the applicant. The applicant hereby authorizes the Indiana Professional Licensing Agency to transmit the applicant's record and all other pertinent information obtained in the course of its investigation to Landscape Architectural Registration Boards of States, Provincial Registars or other political subdivisions registering landscape architects. In consideration of the services to be rendered by the Indiana Professional Licensing Agency, the applicant hereby releases, discharges and exonerates the Indiana Professional Licensing Agency, its officers, directors and agents from any and all liability or every nature and kind arising out of the transmission of information concerning the application. The undersigned, being duly sworn, upon oath deposes and says that he / she is the person making the foregoing statements, and that they are made in good faith and are true in every respect.
Signature of applicant Date (month, day, year)

STATE / PROVINCE OR COUNTRY OF: COUNTY OF: Subscribed and sworn to by the deponent __________________________________________________________________________________ before me at ________________________________________________________ on ______________________________________________ day of _____________________________________________, 20 ____________.

By ______________________________________________________________

NOTARY SEAL