EI complete licensure packet WORD

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					                                      APPLY ONLINE INSTEAD!
 Visit https://pelslicensing.arkansas.gov/ complete your application and pay electronically! View
 the status of your application at any time!

            INSTRUCTIONS FOR COMPLETING PAPER APPLICATION FOR
         ENGINEER INTERN-NONSTUDENT (EI-NS) LICENSE BY EXAMINATION

 USE THIS APPLICATION IF YOU ALREADY GRADUATED:

     1. With an EAC of ABET approved engineering degree: OR
     2. With a non EAC of ABET undergraduate engineering degree plus you have a graduate engineering
        degree from an institution with offers an EAC of ABET approved undergraduate degree in the
        same discipline as your graduate degree; OR
     3. With a non-accredited bachelor of science degree but have had your official transcripts evaluated
        by Board-approved organization and have made of any deficiencies identified, with any engineering
        course deficiencies made up with courses offered by an EAC of ABET–accredited degree program
        or equivalent.

    Applications are only considered after all documents contained in this packet are received by Board
     staff. Once your application is complete, an interview with the Board Members will be scheduled and
     you will receive an email outlining the details

    The Board meets every other month starting in January with special meetings on occasion for the
     purpose of reviewing applications. Therefore once your application is complete it could take up to a
     couple of months for the Members to review your application.

    If you’re overnighting the application packet, our physical address is PELS Board 623 Woodlane Dr.,
     Little Rock, AR 72201 and don’t forget to provide our telephone number (501-682-2824) to the delivery
     company

  Examinations are given in APRIL and OCTOBER:
   o IMPORTANT: Any application completed AFTER the following deadlines will be retained until the
      next testing date.
                                                                                                  st
        APRIL exam – your application must be in the Board’s Office AND complete by JANUARY 1 .
                                                                                                  st
        OCTOBER Exam – your application must be in the Board’s Office AND complete by JULY 1 .

APPLICATION DOCUMENTATION:
1. Application – 3 PAGES must be typewritten (not handwritten) and complete including a photograph of
   yourself taken within the last six months.

2. College Verification –We need verification of each degree received. Only courses beyond high school
   or age 18, will be consider as part of your qualifications.

3. Experience Sheets - Board Members are not familiar with your work and your experience is judged and
   evaluated on the information you provide. Experience information must be detailed, complete, and
   account for all time after the age of 18 or high school graduation. Only experience after your EAC of
   ABET or equivalent degree will be used for evaluation purposes.

4. References – Please ask them to type or print clearly with a ball-point pen. You need to provide:
           a. Three (3), two must be current Professional Engineers licensed in any state or jurisdiction
              who are familiar with your work (not relatives or members of this Board).
           b. All references to the appropriate parties

5. Fees - Fees are Non-Refundable unless waived by Board action. Make your check payable to PELS
   Fund and submit it with your application.
           Engineer Intern, Non-Student:        $115.00 ($50.00 application, $65.00 exam)




 Revised 9/30/2012
      ARKANSAS BOARD OF LICENSURE FOR
  PROFESSIONAL ENGINEERS AND PROFESSIONAL SURVEYORS
                     P.O. Box 3750
             Little Rock, Arkansas 72203
                      www.pels.arkansas.gov
                      Phone (501) 682-2824
                       Fax (501) 682-2827                                   Date Received Application:
           APPLICATION FOR LICENSURE                                        _________________________
            AN AN ENGINEER INTERN                                           Check:    _________________
                   GENERAL INFORMATION                                      _________________________



Name in full         Date
If you have ever used another name list it here
Social Security #           Telephone (H)          (Fax)
Telephone (O)          Ext.
Employer           E-Mail
Preferred Mailing Address            Is this your work address?                   Please tape sides down
City       , State          Zip
Present Position
Place of Birth
                                                                               Attach Recent Photograph
Date of Birth         Age                                                         With Face Not Less
Photo taken on          mo/yr                                                       Then ¾” Wide
Are you a U.S. citizen?           If not, where?
Have you taken the Fundamentals of Engineering (FE) exam previously?
       Yes    No     Where?         When?


                                                           EDUCATION

Graduated from              High School on         , 20

                                                      COLLEGE EDUCATION

INSTITUTION ATTENDED                      PERIOD OF ATTENDANCE                        DATE       DEGREEE
   NAME       LOCATION                     FROM     TO    YEARS           MAJOR      GRADUATED   RECEIVED




        Revised 9/30/2012
                                                             REFERENCES
Give the names of 3 references, not relatives and not members of this Board. Two must be licensed professional engineers
who are familiar with your work.

Name, Title                      Mailing Address—Street and Number                   City           State         Zip Code




MEMBERSHIP IN SOCIETIES, ASSOCIATIONS, OR INSTITUTIONS
                                                    (Professional or Scientific)

Name of Organization                        Location                Grade of Membership                Date of Entrance




  I do herby certify that I have read the Rules and Regulations of the Board, the Rules of Professional Conduct, and by submitting
this application agree to be bound by the Acts of Arkansas, the Rules and Regulations of the Board, the Rules of Professional
Conduct and that a violation of any of the above could be the basis for revocation of my license.

_______________________________________________
Signature of Applicant
                                                                AFFIDAVIT
                        (To be attested before a Notary Public or other officer authorized to administer oaths)

State of _________________________________
County of _______________________________

On the day of ____________________________ , 20 ____ , before the undersigned, a Notary Public, in and for the County and
State

Aforesaid, came_________________________________________________________________________________

a resident of _________________ , County and State of _______________ , known to me as the person herein described and
subscribing hereto, as having signed the form of application attached hereto, and on oath deposes and says that the statements
made are true.
                                  Signature of Affiant _________________________________________

Subscribed and sworn to before me, this ________________ day of ______________________________ , 20___

                                                                    ___________________________________________________
                                                                   (Notary Public)




           Revised 9/30/2012
                                                         ARKANSAS
                                                 STATE BOARD OF LICENSURE
                                              FOR PROFESSIONAL ENGINEERS AND
                                                  PROFESSIONAL SURVEYORS
                                                                   P.O. BOX 3750
                                                           LITTLE ROCK, ARKANSAS 72203

                                                                   www.arkansas.gov/pels
                                                                     Phone (501) 682-2824
                                                                      Fax (501) 682-2827


                                    COLLEGE VERIFICATION REQUEST
Office of Registrar       (College Name)

Applicant’s Name:        (First, Middle and Last Name) S.S.N. #:         Birthdate:        Phone:

Dear Sir or Madam:
The above named individual has filed an application for Licensure with this Board. In regard to his/her education,
he/she states as follows:

List Types of Degrees and Date Received:             ONLY a registrar may complete this form.


                                                            Registrar Completes: place college seal here

                                                       Correct:____________________________________
                                                      Incorrect:___________________________________
                                                      Registrar’s name_____________________________

                                                      Phone number_______________________________

                                                      Date:_______________________________________


Please check your records and advise this Board as to the accuracy of that portion of his/her educational record which
pertains to your school. Your cooperation in this matter will be sincerely appreciated.

                                                 Yours very truly,
                                               Executive Director
                                 ARKANSAS STATE BOARD OF LICENSURE FOR
                                         PROFESSIONAL ENGINEERS
                                       AND PROFESSIONAL SURVEYORS
NOTE: Applicant should complete top portion and forward to college with stamped envelope addressed to Arkansas
Board, P.O. Box 3750, Little Rock, AR 72203-3750.

I am applying for a license with the Arkansas State Board of Licensure for Professional Engineers and Professor
Surveyors (hereinafter referred to as the "Board") and hereby authorize any individual, company or institution to furnish
the Board or any of its employees with any information requested on or by this form or to answer any questions or
inquiries from Board employees, and do hereby release the individual company or institution and all individuals
connected therewith from all liability for any damage whatsoever incurred by me as a result of their furnishing such
information.

Printed Name of
Applicant________________________________Signature______________________________Date____________




           Revised 9/30/2012
                             Arkansas Board of Licensure for
                      Professional Engineers Professional Surveyors
                                                        P.O. Box 3750
                                                   Little Rock, AR 72203


                  Engineer Intern Reference Form

                                                       Applicant’s Name

Note: The applicant will forward this form to each reference. Each reference is requested to complete it fully and
forward it directly to the Board.

                              (Please use black typewriter ribbon or a dark ball-point pen)

PERTAINING TO APPLICANT

1. I have known the applicant for _________ years.

2.   I (am) (am not) related. Relationship _________________________________________________________

3.   Applicant is employed by ___________________________________________________________________

4. Applicant’s general reputation and character are _________________________________________________

5. I believe applicant’s technical ability to be (fair) (average) (good) (excellent) (superior).

6. My business connection with applicant (is) (has been) _____________________________________________
     ________________________________________________________________________________________

7. The following is my evaluation of the applicant’s ability as an engineer_________________________________
     __________________________________________________________________________________
     __________________________________________________________________________________

PERTAINING TO REFERENCE

My business of profession is _____________________________________________________________________

I am a current professional engineer in the state of _____________________________ *Reg.No.______________

I am associated with ___________________________________________________________________________

Address: ____________________________________________________________________________________

 __________________________________ _______________________________________________________
      (Please Type or Print Your Name)       (Your Signature)

Daytime Phone: (      )        -                    Date: _______________________________________________
*ALL NON-ARKANSAS P.E. REFERENCES MUST SUPPLY A COPY OF YOUR POCKET CARD OR A
PRINTOUT FROM YOUR STATE BOARD’S WEBSITE OF YOUR LICENSE TO VERIFY CURRENT
LICENSURE.Mail to: Arkansas Board of Registration for Professional Engineers and Land Surveyors, P.O. Box
3750, Little Rock, AR 72203-3750.

        Revised 9/30/2012
IMPORTANT – Do Not Fill Out until you read and understand this form.                      EI EXPERIENCE SHEETS

1.     Make statements brief and concise, designating each change in position on a separate engagement. Include the scope and complexity of work as
       well as your duties and degree of responsibility. If necessary, additional sheets may by used. (Begin with your earliest experience.)

2.     Each of the six columns under “Time” should be filled out for each engagement, using years and tenths of years (ie. 3 months would be .25, 6
       months would be a .5, and 9 months would be .75). Do not leave blank spaces, and do not use the word “yes”.

3.     The time in “Sub-Professional (non-engineering) Work” (includes all time before date of BS Degree) plus the time in “Professional Work” must
       equal the time entered under “Total Time”. (Total Time must equal calendar time.)

     Date                                                                            Time (Years in Decimals)
                  Title of Position, Name of Employer and                                                                              Name and
From                                                           “Other”                   Professional Work                Total
                  Character of Each Engagement                                                                                         Address
                                                                Work                                                      Time
                                                                            Design    Super- Responsible     Total                     Of Supervisor
            To                                                                                                            Col. 1 + 5
                                                                  (1)                 vision Charge          Col. 2,3,4                Lic. No. if
                                                                              (2)       (3)      (4)            (5)                    Applicable




EI Experience Sheets – last page
Revised 9/30/2012
      Date                                                                               Time (Years in Decimals)
                     Title of Position, Name of Employer and                                                                                Name and
 From                                                              “Other”                   Professional Work                 Total
                     Character of Each Engagement                                                                                           Address
                                                                    Work                                                       Time
                                                                                Design    Super- Responsible      Total                     Of Supervisor
             To                                                                                                                Col. 1 + 5
                                                                                          vision Charge           Col. 2,3,4                Reg. No. if
                                                                     (1)
                                                                                  (2)       (3)      (4)             (5)                    Applicable




Total Time in “Other” Work   ______________________________
Total Time in Design ___________________________________________________
Total Time in Supervision__________________________________________________________
Total Time in Responsible Charge _____________________________________________________________
Total Time in Professional Work __________________________________________________________________________
Total Time (Not to exceed calendar time)_________________________________________________________________________________




 Revised 9/30/2012

				
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