Free 43741.FH11 - Indiana

APPLICATION FOR LANDSCAPE ARCHITECT REGISTRATION
State Form 43741 (R4 / 7-06) Approved by State Board of Accounts, 2006

*Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

STATE BOARD OF REGISTRATION FOR ARCHITECTS AND LANDSCAPE ARCHITECTS PROFESSIONAL LICENSING AGENCY 402 W. Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3022 E-mail: [email protected]

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE ISSUED (month, day, year) DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS.
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) Place of birth (city and state or country) E-mail address State ZIP code Social Security number*

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks

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FIRM / BUSINESS INFORMATION

Name of firm Address (number and street or rural route) City Telephone number (daytime) E-mail address State ZIP code

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Reciprocity with CLARB Reciprocity without CLARB

MAKING APPLICATION BY:
CLARB certificate number State of registration

Date when exam was taken (month, day, year)

State where exam was taken

Initial application Exam
Date of exam (month, day, year)

EDUCATIONAL BACKGROUND NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED (month, day, year) DEGREE EARNED

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LIST ALL STATES IN WHICH YOU HAVE BEEN LICENSED STATE TYPE OF LICENSE, REGISTRATION OR PERMIT NUMBER DATE ISSUED (month, day, year) CURRENT STATUS

Do you hold, or have you ever held, a license, certificate, registration or permit to practice architecture or landscape architecture in Indiana? Yes Indiana license number No (If yes, please answer below.) Date license issued (month, day, year)

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM COLLEGE GENERAL LOCATION DATES

PRACTICAL EXPERIENCE LIST ALL PLACES WHERE YOU HAVE BEEN EMPLOYED TO PRACTICE ARCHITECTURE EMPLOYER Full name and complete current address of employer (begin with most recent, include military and other) DATES OF EMPLOYMENT (month, year) TOTAL TIME EMPLOYED PART TIME FULL TIME

DATES OF EMPLOYMENT

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LANDSCAPE ARCHITECT REFERENCES NAME THREE (3) LANDSCAPE ARCHITECTS WHO ARE PERSONALLY ACQUAINTED WITH YOUR PROFESSIONAL ABILITIES. GIVE COMPLETE ADDRESSES.
Name Address (number and street, city, state, and ZIP code) Name Address (number and street, city, state, and ZIP code) Name Address (number and street, city, state, and ZIP code)

If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any license, certificate, registration or permit that you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit in any state (including Indiana) or country? 4. Are you now being, or have you ever been treated for drug or alcohol abuse? 5. Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes Yes

No No No No No

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Indiana Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency or any of its authorized representatives in connection with processing my application. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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