Free 35178.pdf - Indiana

VERIFICATION OF EMPLOYMENT FOR REGISTRATION AS LAND SURVEYOR
State Form 35178 (R3/3-94)

Indiana State Board of Registration For Land Surveyors Indiana Government Center South 302 W. Washington Street, Room E034 Indianapolis IN 46204-2700

FOR OFFICE USE ONLY
Application Number

LAND SURVEYOR -IN -TRAINING

To Referee: The individual named below is an applicant before this Board to take an examination as a Surveyor - In - Training as the first step toward registration as a Land Surveyor. Your name has been submitted by him / her as an employment reference who is familiar with his / her work, character and general suitability for future registration as a Land Surveyor.

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 Land Surveyors

1. Do you believe that the applicant is competent to be placed in responsible charge of land surveying work?

Yes

No

Uncertain

2. In addition to the above information, you are encouraged to provide comments in the space below which will assist the board in a fair and proper evaluation of this applicant's

land surveying ability.

EMPLOYER INFORMATION
Name of Employer (As provided by Applicant)

If you are NOT REGISTERED, please check box.
Position Registered please affix seal or write state of present registration and your registration number

Name of Company

Address (Number and Street)

City, State, ZIP code

SEAL

Signature

Date

State of Present Registration

Registration Number