Free 04061.PDF - Indiana

ROSTER LISTING - ARCHITECT AND LANDSCAPE ARCHITECT
State Form 4061 (R6 / 1-01) Approved by State Board of Accounts, 2002

Indiana Professional Licensing Agency 302 West Washington Street, Rm. E034 Indianapolis, IN 46204-2246 (317) 232-2980

Please complete this form and return to this agency with registration fee of: If paying December 1 of even year through November 30 of odd year: $50.00 If paying December 1 of odd year through November 30 of even year: $100.00

On the four lines below, insert your name, the address to which you want your mail sent, including city, state and ZIP code. Except in certain abbreviations, the information on these four lines will be used for roster and mailing purposes. In the roster, for alphabetical listing, your last name will appear first followed by the first and middle names or initials, and other identification such as Sr., Gen., Comdr., etc. All of this will appear on ONE line of the roster and must be confined to the number of spaces shown below. NAME (first, middle, last)

MAILING ADDRESS (if company address, include company name)

MAILING ADDRESS (continued)

CITY

STATE

ZIP CODE

SOCIAL SECURITY NUMBER

This agency is requesting disclosure of your Social Security number under IC 4-1-8-1. Disclosure is mandatory; this record cannot be processed without it.

DO NOT WRITE BELOW THIS LINE - FOR AGENCY USE ONLY
Board approval date

Architect Landscape Architect Reciprocity
Application number Registration number

Examination