Free 02146ig.FH11 - Indiana

REFERENCE FOR REGISTRATION AS A PROFESSIONAL ENGINEER
State Form 2146 (R6 / 7-06)

SEND TO: INDIANA STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Rm W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3022 E-mail: [email protected]

Name of applicant Address (number and street) City, state, and ZIP code

Degree of knowledge of applicant

List dates that knowledge of applicant extended From

Basis of knowledge

Very well Well

Slightly Not at all

To

Association in engineering work Being a student in my class

Professional society activities Social and community activities

Character and integrity of applicant

Branch of engineering in which applicant is most proficient

In order to mark the performance of the applicant, read the interpretations below. Also, graduations between the levels shown in boxes may be indicated by the location of your ( x ) or ( ). ü Superior: Performance unquestionable of a professional level demonstrating thorough competence and creative ability. Normal: Work adequate for most engineering purposes, though not distinguished. Indicates an ability to produce workable designs of systems or products at a professional level. Marginal: Performance is adequate on routine tasks. Probably needs careful checking and supervision on more complex projects. Unsatisfactory: Work of poor quality, not up to minimum professional standards at this time. Requires review and revision by associates or supervisors before execution. Inadequate for the "the purpose of safeguarding life, health and property". SUPERIOR NORMAL MARGINAL UNSATISFACTORY

Applicant, by law, shall be qualified to be placed in responsible charge of engineering work. Rate applicant below.

Competent

Not competent

I do not know

In addition to the above information, you are encouraged to provide comments below which will assist the Board in a fair and proper evaluation of this applicant. If necessary, please use reverse side for further comments.

Your name as submitted by applicant Position Company name Address (number and street) City, state, and ZIP code E-mail address Signature Date (month, day, year)

If you are: REGISTERED, please affix PE seal or write State of present registration and Certificate No. NOT REGISTERED, please insert NR.