Free 50535.pdf - Indiana

INDIANA ARCHITECT REFERENCE
State Form 50535 (9-01)

PLEASE TYPE OR LETTER NEATLY

NOTE: Please complete each lettered or numbered item. Incomplete forms will be returned. APPLICANT COMPLETE THIS SECTION
1. Indiana file number 2. Name of applicant

3. Name of reference

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

4. Have you and the reference source attended architectural school together? Yes If Yes, give dates attended: No Name of school

5. Have you been employed in the same firm? Yes No

IF YES, PLEASE SUPPLY THE FOLLOWING INFORMATION: DATES: FROM - TO NAME OF FIRM LOCATION (city, state) APPLICANT'S POSITION REFERENCE'S POSITION

6. FIRST EMPLOYMENT

7. SUBSEQUENT EMPLOYMENTS

8. If answers to items 4 and 5 are "No", how is it that you know the reference?

APPLICANT'S AUTHORIZATION AND RELEASE (MUST BE SIGNED BEFORE SENDING FORM TO REFERENCE) I hereby authorize the Board to make inquiries of the person listed as a reference with respect to my background and character. I invite full and complete response to all inquiries. I release the reference from any and all claims, including claims for libel and slander, which may arise out of the communication of any information to the Board.
9. Signature of applicant 10. Date signed

REFERENCE COMPLETE
A. Is the above information correct as stated? Yes No (if No, please explain) If Yes, how long? (Use additional sheets to explain any special circumstances)

B. To the best of your knowledge, has the applicant ever practiced architecture as a principal?

Yes No Years Months C. Please indicate, to your knowledge, the applicant's ability to practice architecture 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.

EXCELLENT D. TECHNICAL COMPETENCE E. PROFESSIONAL CONDUCT

SATISFACTORY

MARGINAL

UNSATISFACTORY

NOT QUALIFIED TO ANSWER

Person supplying information above, please complete the following relative to yourself. Please type.
F. Name of person completing this reference:

G. Jurisdiction (state) of first architectural registration

H. Year of registration

I. Name of current firm

J. Position in firm

K. Signature of reference

L. Date