Free 04034.PDF - Indiana

Date (month, day, year)

NCEE STANDARD VERIFICATION - ENGINEER
State Form 4034 (R5 / 6-93)

File number

TO:

Indiana State Board of Registration for Professional Engineers Indiana Government Center South 302 W. Washington St., Room E034 Indianapolis, IN 46204-2700 Telephone: (317) 232-2980

Name

Street address

FROM:
City, state and ZIP code

Date of birth (month, day, year)

The above named person was registered as: Engineering Intern Professional Engineer

CERTIFICATE NUMBER

DATE ISSUED

VALID UNTIL

Basis of Registration: Written Examination FE PE Oral Examination EI accepted from: PE accepted from: Other
Remarks

HOURS

RESULTS

NCEE

EXAM DATE

__________ Hrs PE

BOARD S EAL
By: Title Date (month, day, year)