Free 44668.FH11 - Indiana

ARCHITECT / LANDSCAPE ARCHITECT VERIFICATION OF EMPLOYMENT
State Form 44668 (R3 / 8-06)

Reset Form

INSTRUCTIONS:

1. 2. 3. 4.

Please type or print legibly. Please complete each numbered or lettered item. Incomplete forms will be returned. All applicants complete the top half of form. A qualified individual must complete the bottom portion of form. Please do not detach these forms. APPLICANT COMPLETE
2. Name of applicant

PROFESSIONAL LICENSING AGENCY INDIANA STATE BOARD OF REGISTRATION FOR ARCHITECTS 402 West Washington Street, Room W072 Indianapolis, IN 46204 T elephone: 317-234-3022 E-mail: [email protected]

1. Indiana file number (For office use only)

3. Current address (number and street, city, state, and ZIP code) 4. Was / Is employed by the firm: 5. Address of firm (number and street, city, state, and ZIP code) 6. DATES OF EMPLOYMENT 7. LENGTH OF TIME 8. STATUS (Check one)
CORP. DIRECTOR OTHER (EXPLAIN)

9.
SCHEMATIC DESIGN SITE & ENVIRONMENTAL ANALYSIS

INDICATE % OF TIME SPENT IN EACH PRACTICE CATEGORY
CONSTRUCTION PHASE - OBSERVATION TEACHING/RESEARCH SPECS & MATERIALS RESEARCH

CODE RESEARCH

DOC. CHECKING & COORDINATION

BUILDING COST ANALYSIS

PROGRAMMING

FROM

TO

FULLTIME

MO DAY YR MO DAY YR

3

HOURS/WEEK

10. Does the firm or an affiliate of the firm engage in construction? Yes 11. Indicate services rendered by the firm: Architecture Engineering Real Estate Development Registered Architect Registered Engineer No Landscape Architect Other (explain on separate sheet) Planner Other (explain on separate sheet)

Planning Interior Design / Contract Interiors Construction Management Landscape Architect Interior Designer

12. Position of supervisor

APPLICANT'S AUTHORIZATION AND RELEASE (This release must be signed before sending the form for completion below)
I hereby authorize the BOARD to make inquiries of the person listed below with respect to my background and character. I invite full and complete response to all inquiries. I release said person from any and all claims, including claims for libel and slander, which may arise out of the communication of any information to the BOARD. 13. Signature of applicant 14. Date signed (month, day, year)

SPONSOR COMPLETE This portion of the form must be completed by applicant's employer / supervisor at the referenced firm. Applicants must have this portion completed by their sponsor at the referenced firm.
A. Are the dates of employment as shown in item 6 correct? Yes No If No, please clarify:

B. Has the applicant worked under the direct supervision of the individual indicated in item 12 above? Yes No If No, please clarify: C. Are the experiences shown by the applicant in item 9 above correct? Yes No If No, please clarify: D. Indicate, to the best of your knowledge, the applicant's ability by placing an "X" in the appropriate spaces below. If unsatisfactory box is checked for technical competence or professional conduct, please submit a letter of explanation with this form. E. ON LATEST DATE OF EMPLOYMENT
EXCELLENT SATISFACTORY MARGINAL UNSATISFACTORY UNKNOWN EXCELLENT

F ON DATE OF THIS REPL . Y
SATISFACTORY MARGINAL UNSATISFACTORY UNKNOWN

TECHNICAL COMPETENCE PROFESSIONAL CONDUCT G. Name of person completing this half of form I. Position in firm named in item 4 above (or relationship to firm) J. Name of current firm Address of current firm (number and street, city, state, and ZIP code) K. Position in current firm L. Signature of sponsor M. Date signed (month, day, year) H. Year(s)/state(s) of professional registration(s) (If none, indicate N/A)

BIDDING PROCEDURES

OFFICE PROCEDURES

EMPLOYEE

PART-TIME (Less than 35 hours per week)

CONSTRUCTION DOCUMENTS

CONSTRUCTION PHASE - OFFICE

DESIGN DEVELOPMENT

PARTNER