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Fillable Printable Application For Registration As An Engineering Intern

Fillable Printable Application For Registration As An Engineering Intern

Application For Registration As An Engineering Intern

Application For Registration As An Engineering Intern

STATE BOARD OF REGISTRATION
FOR PROFESSIONAL ENGINEERS
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, IN 46204
Telephone: (317) 234-3022
E-mail: pla10@pla.IN.gov
www.pla.IN.gov
FOR OFFICE USE ONLY
APPLICANT INFORMATION
EDUCATIONAL BACKGROUND
DATES OF ATTENDANCE
(month, day, year)
LOCATION OF SCHOOLNAME OF SCHOOL
Name of firm
Address of firm (number and street)
City State ZIP code
Business telephone number
( )
Website address
DEGREE EARNED
Qualification for Registration according to IC 25-31-1-12 must be met at time of application.
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Are you the spouse of a member of the military who is assigned to a duty station in Indiana?
(Optional)
Yes No
Are you an active duty member of the military? (Optional)
Yes No
Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)
I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).
Name of applicant (last, first, middle, maiden)
Date of birth (month, day, year)
Address of applicant (number and street or rural route)
Social Security number
*
Telephone number (daytime)
( )
City, state, and ZIP code
E-mail address (required)
Place of birth (city and state or country)
Gender **
Male Female
DO NOT WRITE ABOVE THIS LINE
APPLICATION FOR REGISTRATION AS
AN ENGINEERING INTERN
State Form 55680 (R2 / 9-17)
Approved by State Board of Accounts, 2017
APPLICATION FEE
DATE FEE PAID (month, day, year)
RECEIPT NUMBER
LICENSE NUMBER
DATE OF ISSUE (month, day, year)
APPLICANT
Attach one (1) passport type
quality photograph of
yourself taken within the last
(8) eight weeks.
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
** This information is being requested for workforce statistical purposes only; disclosure is voluntary.
INSTRUCTIONS: 1. The fee for this application is $10.00, payable to the Indiana Professional Licensing Agency, in accordance with 864 IAC 1.1-12-1.
2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
Reset Form
EXAMINATION
FE EXAM TAKEN ON (month, day, year): ______________________
REFERENCES
REFERENCE PE
LICENSE NUMBER
NAME OF REFERENCES
LIST ACQUAINTANCE, EMPLOYER,
ASSOCIATE, ETC.
EXPERIENCE - ATTACH ADDITIONAL SHEET IF NECESSARY.
Name of current employer
Address (number and street, city, state, and ZIP code)
Duties:
Name of supervisor
Number of hours worked per week
Job title Date of employment (month, day, year)
Full time
Part time
Name of previous employer
Address (number and street, city, state, and ZIP code)
Duties:
Job title
Date of employment (month, day, year)
Full time
Part time
Name of supervisor
Number of hours worked per week
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PERSONAL BACKGROUND
1. Have you previously applied for or taken the EI/PE examination in Indiana or any other state?
2. Has disciplinary action ever been taken regarding any license, certificate, registration or permit you hold or have held?
3. Have you ever been denied a license, certificate, registration or permit in any state (including Indiana)?
4. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor, or felony
in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
5. Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left
untreated may interfere, with your ability to practice in a competent and professional manner?
Yes No
Yes No
Yes No
Yes No
Yes No
If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation
of the license or permit issued pursuant to this application.
Yes No
Yes No
Yes No
Yes No
APPLICATION AFFIRMATION
I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Date signed (month, day, year)
Signature of applicant
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing
Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of their authorized representatives
in connection with processing my application for registration to practice Engineering.
I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to
such inspection or furnishing of any such information.
A photostatic copy of this authorization has the same force and effect as the original.
AFFIRMATION
Signature of applicant
I hereby swear or affirm, that I have read the above statements and agree to same.
Date signed (month, day, year)
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