Free 43715.PDF - Indiana

Date (month, day, year)

NCEES STANDARD VERIFICATION - LAND SURVEYOR
State Form 43715 (R2 / 4-02) File number

TO:

State Board of Registration for Land Surveyors 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: Land Surveyor-in-Training Professional Land Surveyor

CERTIFICATE NUMBER

DATE ISSUED

VALID UNTIL

Basis of Registration: Written Examination FLS PLS Oral Examination SIT accepted from: PLS accepted from: Other
Remarks

HOURS

RESULTS

NCEE

EXAM DATE

__________ Hrs PLS

BOARD SEAL
By: Title Date (month, day, year)