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DO NOT WRITE IN THIS SPACE


OFFICE RECORD
RECEIVED________CARD_______

FEE$_________CK( ) MO( ) BD( )

APPLICATION NO.______________

CLK’S INITIALS________________








Application for Examination for

Engineer-In-Training


$121.00

Make check payable to :

DLLR-PE

See page 10 of instructions for exam



dates and filing deadlines.



Application for

Professional Engineer

Licensure by Examination

$171.00

make check payable to:

DLLR-PE

See page 10 of instructions for exam dates and filing deadlines.





Application for

Professional Engineer

Licensure by Reciprocity

$100
Make check payable to : DLLR-PE


I
STATE OF MARYLAND

DEPARTMENT OF LABOR, LICENSING AND REGULATION



STATE BOARD FOR PROFESSIONAL ENGINEERS

500 N. CALVERT STREET, ROOM 308

BALTIMORE, MD 21202-3651

PHONE: 410-230-6322 FAX: 410-333-0021

TTY users call Maryland Relay Service

FORM 1

MPORTANT NOTICE:
SEND ALL MATERIALS, INCLUDING YOUR FEE AND APPLICATION, TO:

STATE BOARD FOR PROFESSIONAL ENGINEERS, 500 N. CALVERT STREET, ROOM 308, BALTIMORE, MD. 21202-3651.

FEE IS NON-REFUNDABLE AND SUBJECT TO CHANGE WITHOUT NOTICE


DEADLINES ARE FINAL. POSTMARKS ARE NOT ACCEPTABLE.
FULL NAME:           

LAST NAME (NAME ON TRANSCRIPT IF DIFFERENT)
           

FIRST MIDDLE (IF YOU DO NOT HAVE A MIDDLE NAME, ENTER “N.M.N.”)


ADDRESS (Street)      


(City)      




(County)       (State)       (9-digit Zip)      




Telephone No.: Day_______________ Evening ___________________ E-Mail Address:




Social Security Number_________________________ If not US Citizen: INSA # A_____________________________

(Required By Federal & State Law)

Date of Birth ____________________________________ Place of Birth_________________________________


1. My P.E. application is filed under the subsection checked: (see Section V.-B of directions)  14-305(b)  14-305(c)  14-305(d)
2. My major field of engineering is______________________2a. Discipline I wish to be examined in: ______________
3. Have you passed the Fundamentals Examination?  YES State_______________ Date_______________

 NO If NO file under 14-305(d) ONLY. (P.E. CANDIDATES)

4. Has licensure ever been denied? ___________ suspended? ________________ revoked?__________________

If YES, explain on a separate 8 1/2 x 11 sheet. (typed)

5. Do you hold an unexpired license as a professional engineer?  YES  NO

If YES, State_______________ License No.________________ Expiration Date_______/____/______


6. Have you ever been convicted of a felony or misdemeanor in any State or Federal court? YES  NO
7. Have you ever been found guilty of misconduct, incompetence, or gross negligence in any jurisdiction? YES  NO
8. Have you been convicted of or received probation before judgment of any drug offense committed after January 1, 1991?  YES  NO
If you answered YES to any question(s) 6-8, submit a letter giving complete explanation and a true test copy of the

applicable court document(s). Also, notify the appropriate state licensing board to send a copy of the final order

in your case directly to the Maryland Board.

P
FORM: DLLR/P/3-PE/1/02rev


age 1 of 2

9. EDUCATION EAC/ABET Approved


           

____________________________________________________________________________________  YES  NO

Name of College or University Degree Graduation Date
           

____________________________________________________________________________________  YES  NO

Name of College or University Degree Graduation Date
NOTE: An official academic transcript must be sent to the Board's office directly from the college registrar. Transcripts marked "issued to student" will not be accepted. Foreign Degree applicants: See Section V,- E,3 of the instructions.
10. The endorser numbers below must correspond to the numbers in the ENDORSER NUMBER boxes at the top right corner of the individual

RPE Forms. See instructions for Form 1. PROFESSIONAL ENGINEER EXAMINATION APPLICANTS ONLY.


Endorser No.

Company or Employer Name

(Enter earliest engagement first)






Name of Endorser




Time Claimed

Mo/Yr to Mo/Yr






Number of

RPE form


1.

     




     




     

to

     




     

2.

     




     




     

to

     




     

3.

     




     




     

to

     




     

4.

     




     




     

to

     




     

5.

     




     




     

to

     




     

6.

     




     




     

to

     




     

11. REFERENCES OF CHARACTER - (PE EXAM AND RECIPROCITY APPLICANTS ONLY) "This certifies that I have been personally

acquainted with the applicant since the year indicated opposite my name; that I have read the foregoing statements, which so far as

known to me are correct; that I believe the applicant to be of good character and repute. " Signatures are required below of not fewer



than five citizens unrelated to applicant, at least three of whom must be professional engineers, with license number listed, and



Date




Signature




Complete Address




Occupation




Known Since




License No.



















PE































PE































PE















































































12. I understand that by signing this statement, the license for which I am applying will expire two years from date of issue and that I will be

required to renew this license and pay the renewal fee prior to the expiration date. I further understand that I may not engage in the

occupation or profession for which I am applying until such time as a license has been issued to me.


13.  I am not an employer required to provide employee compensation under the Workers' Compensation Law.

 I have workers' compensation coverage, policy/binder no. _________________ Issued by the ____________________________


14. In accordance with Executive Order 01.01.1983-18, the Department of Labor, Licensing and Regulation is required to advise you as follows regarding the collecting of personal information: Personal Information requested by the licensing agency of the Department is necessary in determining your eligibility for licensure. Such personal information is also intended for use as an additional means of verifying the licensee's identity or to enable the agency to communicate, in a timely manner, with the licensee should the need arise. The licensee has a right to inspect his/her personal record and to amend or correct the personal data if necessary. Personal information is generally available for inspection by the public only in accordance with the Public Information Act. Personal information is not routinely shared with state, federal or local government agencies.
15. "I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO

THE BEST OF MY KNOWLEDGE AND BELIEF. I further authorize the release of any information contained within this agreement to an authorized representative of the Department of Labor, Licensing and Regulation for further investigation." "I certify that I have paid all

undisputed taxes and unemployment insurance contributions payable to the Comptroller or the Department of Labor, Licensing and

Regulation or have provided for payment in a manner satisfactory to the unit responsible for collection."

Signature of Applicant _______________________________________________________________________DATE ___________________
Page 2 of 2

F
ENDORSER NUMBER _____
SHEET NUMBER
_____ OF _____

SHEET NUMBER____of____


orm 2



STATE OF MARYLAND

DEPARTMENT OF LABOR, LICENSING AND REGULATION

STATE BOARD FOR PROFESSIONAL ENGINEERS

REPORT OF PROFESSIONAL EXPERIENCE (RPE)
INSTRUCTIONS TO APPLICANT: After reading instructions, complete Section I and Section III (back), make a copy for your records,

and forward this original RPE Form to your endorser. Be sure the endorser number in this box at the top right corner of his form corresponds with the appropriate endorser number and information on the back of Form 1. SECTIONS I, II AND III MUST BE TYPED.




SECTION I: TO BE COMPLETED BY APPLICANT. (This section must be typed.)
Name: ________________________________________________________________________________________________________

LAST FIRST MIDDLE

Address: ______________________________________________________________________________________________________

STREET CITY STATE ZIP

Telephone: (home) ____________________________ (work) ______________________________ Date of Birth __________________
Social Security Number: ___________________________________
Experience described on the reverse side of this RPE form was obtained while employed by:
Firm or Organization Name: _______________________________________________________________________________________
Endorser's Name: ___________________________________________________________________Phone #_____________________
Address: ______________________________________________________________________________________________________

STREET CITY STATE ZIP

Beginning ___________ Ending ___________  Full Time  Part Time, ________ hrs/wk
I hereby certify that the work experience described on the reverse side of this RPE Form and the time claimed for that experience are

true and accurate.

____________________________________________________________

APPLICANT’S SIGNATURE DATE



SECTION II: TO BE COMPLETED BY ENDORSER (Please type)


INSTRUCTIONS TO ENDORSER:

1. Read carefully the applicant's Report of Professional Experience on the back of this RPE Form and any continuation sheets.

2. Provide the requested information below and answer questions 1-6. Please type.

3. If you disagree with any information presented by the applicant on this form, or wish to provide any other information for consideration by the Board relative to the applicant, please submit a separate letter with this form. If you do so, please identify the applicant by full name and social security number in your letter and indicate that they are an applicant for professional engineer examination.

4. SIGN THE ENDORSER'S AFFIDAVIT IN SECTION IV ON THE BACK OF THIS FORM AND AT THE BOTTOM OF EACH RPE CONTINUATION SHEET (Form 2a), IF ANY, or if you do not sign this affidavit, please explain in a separate letter and attach it to this form.

5. DO NOT RETURN ORIGINAL TO THE APPLICANT.
Maryland Department of Labor, Licensing and Regulation

State Board for Professional Engineers

Mail completed form to: 500 N. Calvert Street, Room 308

Baltimore, Maryland 21202-3651


Endorser Name: _________________________________________________________________________________________________
Current Address: ________________________________________________________________________________________________

STREET CITY STATE ZIP


Are you a licensed Professional Engineer?  YES  NO If "YES" - State __________ License No. __________
WITH RESPECT TO THE APPLICANT'S REPORT OF PROFESSIONAL EXPERIENCE AS DESCRIBED ON THE BACK OF THIS FORM:

1. Does the description accurately reflect the work personally performed by the applicant?  YES  NO

2. Does the time claimed by the applicant for this experience reasonably reflect the actual time?  YES  NO

3. Was the applicant's work performed in an adequate and professional manner?  YES  NO

4. Are you attaching a separate letter with additional information about the applicant?  YES  NO

5. IDENTIFY YOUR WORK RELATIONSHIP WITH THE APPLICANT AT THE TIME (LINE SUPERVISOR, PROJECT ENGINEER, WORK DIRECTOR, ETC.). IF NONE EXPLAIN.

____________________________________________________________________Position ___________________________________

6. Comments: ________________________________________________________________________________________________

Page 1 of 2


REPORT OF PROFESSIONAL EXPERIENCE


SECTION III: TO BE COMPLETED BY APPLICANT. (Must be typed)




A. Describe your general engineering duties during your employment with the firm named on the front of this RPE:


B. Describe, in separate paragraph(s), the specific kinds of engineering work you personally performed while employed by the firm named on the front of the RPE. Use specific assignments as examples and describe how these comply with the definition of "Practice Engineering" in the Instructions, Section VII. Then indicate separately in the TIME column at the right, the time you spent on each such kind of work. If you need more than one endorser from a single firm, USE SEPARATE

RPE FORMS FOR EACH ENDORSER. If you do not have sufficient space on this form to fully report the experience to be

v





TIME

YRS

MOS







TOTAL THIS SHEET






erified by a single endorser, use one or more RPE Continuation Sheets (Form 2a). BOTH YOU AND YOUR ENDORSER MUST SIGN EVERY SHEET.

Indicate the number of RPE CONTINUATION SHEETS (Form 2a) for this endorser. If zero, enter "0" 

Were you supervised by a P.E.?  YES  NO Evidence Attached?  YES  NO
C. Describe briefly your personal level of responsibility or authority for the work described above. Explain here any

changes in your title resulting from promotions or other job changes during this period of employment.




SECTION IV: ENDORSER'S AFFIDAVIT. (Also complete Section II on other side.)

I have read the applicant's Report of Professional Experience, I hereby certify that I am knowledgeable about, and qualified to attest to, the applicant's work and engineering ability and that, except as otherwise noted on the front of this form, or in attached correspondence, the work experience described by the applicant and the time claimed therefore are generally true and accurate.

Endorser's Signature



 I cannot so certify. Letter of explanation attached

Date
Page 2 of 2


FORM 2A


ENDORSER NUMBER

______
SHEET NUMBER ____of____

STATE OF MARYLAND

DEPARTMENT OF LABOR, LICENSING AND REGULATION

STATE BOARD FOR PROFESSIONAL ENGINEERS

RPE CONTINUATION SHEET

Name:___________________________________________________________________ _____-_____-_____

LAST FIRST MIDDLE SOCIAL SECURITY NO.
Signature:_______________________________________________________________ Date of Birth ____/___/___








TIME

YRS

MOS






Total this sheet









Total this endorser





SECTION IV: ENDORSER'S AFFIDAVIT:
I have read the applicant's Report of Professional Experience. I hereby certify that I am knowledgeable about, and qualified to attest to, the applicant's work and engineering ability and that, except as otherwise noted on the front of this form, or in attached correspondence, the work experience described by the applicant and the time claimed therefore are generally true and accurate.

ENDORSER'S SIGNATURE (If P.E., so note)


DATE


Page 1 of 1



FORM 3

VERIFICATION OF LICENSURE

TO: Maryland State Board for Professional Engineers

(TITLE OF BOARD REQUESTING CERTIFICATION)

500 N. Calvert Street . Room 308 . Baltimore, Maryland 21202-3651

(410) 230-6322 • FAX: (410) 333-0021

TTY users call Maryland Relay Service


BOARD OF PRIOR LICENSURE










STATE BOARD

(NAME OF APPLICANT)

ADDRESS

(STREET ADDRESS)




(CITY) (STATE) (ZIP)
Social Security No.











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