Free 03826.PDF - Indiana

VERIFICATION OF REFERENCE FOR REGISTRATION AS LAND SURVEYOR
State Form 3826 (R3 / 5-93)

Application number

Indiana State Board Of Registration For Land Surveyors Indiana Government Center South 302 West Washington Street, Room E034 Indianapolis In 46204 APPLICANT INFORMATION
Name of applicant (first, middle, last)

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

The above named applicant has submitted your name as a reference. This reference form is to assist the Board in a fair and proper evaluation of the applicant's work experience in land surveying, and is for: Verification of applicant's employment
1. The applicant was employed by you

Personal knowledge of applicant's work experience Full time [forty (40) hours or more per week] Part time (____________ hours per week)

From:

To:

2. The applicant's character and integrity are:

3. While in your employ, or of your own knowledge, the applicant's duties were:

WORK PERFORMED

PERCENTAGE OF TIME

Above Average

PROFICIENCY Average

Below Average

Rodman-Chainman Instrumentman Party chief Computations Plot preparation Deed research Descriptions Sub-division design Office manager Client contact Other 4. While in your employ, or of your own knowledge, the applicant had responsible charge or experience in performing these types of surveys TYPE OF SURVEY YEARS OF RESPONSIBLE CHARGE EXPERIENCE YEARS Survey location reports (mortgage) Minimum standards Highway or Route Construction Topographic Cartographic or Mapping Hydrographic Photographic Horizontal control, 1st or 2nd Order Vertical Control, 1st or 2nd Order Mining Restoration of Section Corners Geodetic Cadastral Satellite Positioning Other (specify) (Continued on reverse side)

5. List any appropriate comments with regard to applicant's responsible charge of work, experience, education, or other attributes the applicant has that you would like to convey to the board.

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

Yes

No

Uncertain If you are not registered, please insert NR below. If you are registered, please affix LS seal or write state of present registration and your registration number.

Your name (as provided by the applicant)

Position

Name of company

Address (number and street)

City, state, ZIP code Date signed (month, day, year)

Signature