Free 04067.PDF - Indiana

REPORT OF EMPLOYEE ATTENDANCE FOR PROFESSIONAL ENGINEERS AND LAND SURVEYORS EXAM
State Form 4067 (R3/11-02) *This agency is requesting your social security number pursuant to IC 4-1-8-1 which is mandatory. Name Address (number and street, city, state, ZIP code)

INDIANA PROFESSIONAL LICENSING 302 W. WASHINGTON ST. RM. E034 INDIANAPOLIS, IN 46204 (317)-232-2980

* Social Security number

To assist in analysis required for future budget preparation, please complete the following information: Section Section Hours

Writing Exam Questions:
PROFESSIONAL ENGINEER Section Number Hours

Scoring Exam Papers:
Section LAND SURVEYOR Section Hours

Writing Exam Questions:
Section Number Hours

Scoring Exam Papers:

Hours

PROFESSIONAL ENGINEER AND LAND SURVEYOR EXAM PROCTORING
Hours

ENGINEERING INTERN EXAM PROCTORING ENGINEERING INTERN EXAM PREPARATION (Administration Other than Proctoring)
Hours

TOTAL HOURS