Civil Engrng

Professional Engineering Form 4A

The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Division of Professional Licensing Services 89 Washington Avenue Albany, NY 12234-1000

VERIFICATION OF PROFESSIONAL EXPERIENCE

Applicant Instructions
Complete Section I and Section II and be sure to sign and date the attestation on page 3. Make a copy foryour records and forward this original form to your endorser. Use a separate Form 4A for each endorser. If the endorser is/was not your immediate supervisor, refer to “Instructions For Completing Professional Experience Forms”. Section II must be typed or printed legibly. This form may be copied as needed.

SECTION I: Applicant Information

1

Social Security Number
(Leave this blank if you donot have a U.S. Social Security Number)

Endorser number
(From Form 4)

2

Birth Date

Month

Day

Year

3

Print Your Name Exactly as You Wish it to Appear on Your License Last First Middle

4

Mailing Address (You must notify the Department promptly of any address or name changes.) Line 1 Line 2 Line 3 City State Country/ Province Zip Code

5

Telephone/E-Mail AddressDaytime Phone E-Mail Address (Please print clearly)

Area Code

Phone Number

Extension

6

Experience described on this form was obtained while employed by:

Firm or Organization Name: ___________________________________________________________________________________________ Address:___________________________________________________________________________________________________________ Beginning: _______ / _______ / _______ and ending _______ / _______ / _______ Mo. Day Yr. Mo. Day Yr. Full time Part time __________ hrs./wk Professional Engineering Form 4A, Page 1 of 4, June 2004 Total time claimed _________ | __________ Years Months

SECTION II: TO BE COMPLETED BY THE APPLICANT (TYPE OR PRINT LEGIBLY).

Applicant Social Security Number: ____________________________Endorser number
(From Form 4)

A.

Describe your general engineering duties during your employment with this firm for the time period covered by this report.

B.

Describe briefly your personal level of responsibility or authority for the work described for this endorser. Explain here any changes in your title resulting from promotions or other job changes during this period of employment.C.

Describe in detail the specific engineering work you personally performed on several projects or job assignments that are representative of the work you performed while you were employed by the firm named on this form. Then, indicate at right, the time you spent on these projects or assignments. The total time you claim cannot exceed actual calendar time. Describe your work in sufficientdetail. No one time period can exceed two years in duration. In your description you must demonstrate that at least two years of your experience required knowledge and use of codes and practices used in the United States. You must use a separate Form 4A for each individual endorser (even if two or more endorsers work in the same firm). BOTH YOU AND YOUR ENDORSER MUST SIGN FORM 4A..

TIMEYRS./MOS.

Total time this sheet Indicate the number of SHEETS for this endorser. (this is sheet 1) Professional Engineering Form 4A, Page 2 of 4, June 2004 Total time this Endorser

Form 4A - Part C. Continued

Applicant Social Security Number: _____________________________________

Pg ____ of ____
Endorser number
(From Form 4)

TIME YRS./MOS.

Total time this sheet Enter the total timeof work experience with this endorser here and on the appropriate endorser line on Form 4. Attestation I hereby certify that the work experience described on this form and the time claimed for that experience are true and accurate. ___________________________________________________________________________________________________________________________
Applicant's signature

Total time this...