VERIFICATION OF WORK EXPERIENCE - (F4)

Applicant's Name:
Address:

has applied to this Board for registration under the provisions set forth in Section 32113, Public Law 30-35 as


Engineer Intern Land Surveyor Intern Architect
Professional Engineer Profesional Land Surveyor Landscape Architect

In order that the applicant's qualification and experience may be evaluated properly, your assistance in answering the following questions is appreciated.

After completing this form, please sign, stamp or seal and return it in a sealed envelope to the applicant at your earliest convenience as no action will be taken until we receive your verification.  This verification is CONFIDENTIAL and will not be accepted by the Board if not properly filled and sealed.  Thank you for your assistance.


Sincerely,



 
   
1. Do you confirm the accuracy of the applicant's claim that he was working under your immediate supervision:
  Yes   No     from / / to / /
Other:
2. During the time indicated above, were you registered as a Professional Engineer, Architect, Landscape Architect or Land Surveyor?  Yes   No
3. If your answer to No. 2 is (Yes), please indicate the type of profession/branch registered in, certificate number, and the date and state of your original registration:
Engineer      
  Certificate #: Date: / / State:
  Branch
 Architect      
  Certificate #: Date: / / State:
 Land Surveyor      
  Certificate #: Date: / / State:
 Landscape Architect      
  Certificate #: Date: / / State:
4. If your answer to No. 2 is (No), what was the scope of your supervision? 


5. Please comment on the type of work the applicant performed while under your immediate supervision:
6. Do you or did you have supervision or review and approval responsibility over applicant’s work?   Yes   No
If yes, how long?
Comments:        
7. Additional comment on applicant’s professional knowledge and ability:


 

I, the undersigned, being duly sworn, depose and say, THAT, I have executed the above and foregoing statements and acknowledge that they are true in substance and effect and are made in good faith.

Please PRINT the following:

  Your Name:
  Your Company/Business Name:
  Your Address:


Signature — Immediate Supervisor

SUBSCRIBED AND SWORN to before me this day of , 20 .


Signature of Notary Public
(SEAL)

My commission expires: