Free 15199.FH11 - Indiana

QUESTIONNAIRE ON APPLICANT REFERENCE FOR PROFESSIONAL ENGINEERS
State Form 15199 (R7 / 7-06)

INDIANA STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS PROFESSIONAL LICENSING AGENCY 402 W. Washington St., Rm W072 Indianapolis, IN 46204 Telephone: (317) 234-3022 E-mail: [email protected]

ENGINEERING INTERN

To Referee: The individual named below is an applicant before this Board to take an examination as an Engineering Intern as the first step toward registration as a Professional Engineer. Your name has been submitted by him / her as a reference who is familiar with his / her work, character and general suitability for future registration as an engineer. To the extent of your knowledge of this individual, the Board will appreciate your prompt cooperation in furnishing the desired information in the enclosed signature sealed envelope and returning to the applicant.

State Board of Registration For Professional Engineers

REFERENCE INFORMATION
Name of applicant In what branch of engineering did he or she work? What describes his or her work function? (check all that apply) Period covered (month, day, year)

From

To

Research
Evaluation of his or her work

Construction Normal Good

Development Marginal Satisfactory

Supervision Unsatisfactory Poor

Design

Sales

Manufacturing

Other

Superior Excellent
Comments:

His or Her potential as an engineer

Unknown

Signature Address (number and street, city, state, and ZIP code)

Date (month, day, year)

AN EQUAL OPPORTUNITY EMPLOYER