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NEVADA STATE BOARD OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS 1755 East Plumb Lane, Suite 135, Reno, Nevada 89502 (775) 688-1231 1-800-728-2632 (In Nevada only)

Application for Engineer Intern Certification

Exam (Fee $70.00)

The Appropriate Application Fee Must Accompany This Application (Make checks payable to Nevada Board of PE & LS)

This Fee is Not Refundable (NRS 625.390 - 4)

Attach here, with clear tape, an unmounted, recognizable photograph (approx. size 2” X 2.5” overall), not profile, not retouched, taken within one year of submission of this application.

Name

Engineer Intern

Classification

Except for photo (at right, the remainder of this page will be completed by Board Staff

Intern # Date of Certification

Date Received ___________ Fee $________ Check # ___________ Exam _______________________ Board Approval _________________ Re-Exam Fee $_________________ Exam _______________________ Waiver of Notice ___________ Re-Exam Fee $_________________ Exam _______________________ State Verification _______________ Re-Exam Fee $_________________ Exam _______________________ Transcripts ______ Exam _______________________ Child Support Declaration _________ References 1__2__3__4__ INS Doc ________

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To Be Completed by the Applicant. Application & all forms must be typewritten (forms are interactive) Name .........................................................................……………...................... Soc. Sec.# ...........-...........-.............. First MI Last ( Legal name as it will appear on your license ) Firm ................................................................................................... Title ............................................................... Bus. Address ................................................................. City ..............................................St...........Zip...................... Business Telephone Main # (.........)..........................…............... FAX # (.......)..……................................................. Res. Address ................................................................ City ...............................................St...........Zip .................... Preferred Mailing Address: Business Home Telephone : Home (.........)....…..................….............. State of Legal Residence .................................... Length of such residence - Years.................. Mos. ...…............. Birthplace....................................................................................................... Date of Birth .....................…................. Citizenship Information - Pursuant to NRS 625.390 (7) & NAC 625.210 (3) United States of America - Native Born

Naturalized US Citizen Where? ...................................................………....... Date .…...../........./.............

Other - Name of Country .................................................. INS Status..........................A#.................................

Certification Requested – Engineer Intern

Discipline – College Major........................................................ Give the following information about any written examinations passed: Fundamentals of Engineering State ....................... EI#..................... NCEES yes.......no...... # Hrs. 8 Other (Discipline).......................... State .....….............. #..................... NCEES yes.......no...... # Hrs.

Other (Discipline)..................….. State ......….............. #.................… NCEES yes.......no...... # Hrs. ...... List the jurisdiction(s) in which you now hold any valid license(s) - give State, Discipline and License Number(s):

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Education List completed or currently attending. Official Transcript(s) Are Required directly from University - Pursuant to NAC 625.210 (2)

University or College City/State Degree Granted Date ........................................................... ............................................. ......................................... ......................... ........................................................... ............................................ ......................................... .........……......... ........................................................... ............................................ ......................................... ........................

If not a graduate, how many credits have you earned toward a degree in Engineering? ................ List other Engineering courses you have taken (graduate, extension, correspondence) - give date and place: ........................................................................................................................................................................ List Engineering Societies, Associations or Institutes in which you presently hold membership:

______________________________________________________________________________________________ Email Address:

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Applicant’s Name ________________________________ ENGINEERING EXPERIENCE RECORD Important: Do not fill out until you read and understand this form.

For each employment, list experiences in the following format: Must be typewritten (1) Position title (2) Name & Location of Employer (3) Character of Experience Make explicit statements listing specific projects for which you had full or partial responsibility, defining design and related experience, including statements of extent and complexity of the work performed on those projects. Formal, written job descriptions are not acceptable to describe work performed. List employment in chronological order with the earliest engagement first. All time since graduation from college must be accounted for, including military service, illness, non-engineering employment, unemployment, etc. Experience prior to graduation may not be accepted. List “Name, Address, & Phone # of Immediate Supervisor” for each employment engagement. (Copy additional sheets to thoroughly describe your experience)

Dates Position title: Engineering Non Engineer From: Employer Name: Experience Employment Employer Location: yrs. mos. yrs. mos To: .

Supervisor Name & Address:

Employment detail:

Page ____ of ____ Total reported on this page Total time verified

by Board TOTAL TIME REPORTED – ALL PAGES (Total employment time may not exceed calendar time) yrs. ____mos.____

NOTE: The Board is challenged with determining the application of engineering principals throughout your work experience.

Ensure that your application clearly and completely delineates your “engineering related” experience. 3

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References Please refer to NRS 625.183 (4,b & 5,c), NRS 625.390 (3), and NAC 625.210 (1)

List names, license information and company of the four Professional Engineers to whom you sent references. (Note: References are not required for intern applicants who are current, full-time students in Nevada Universities)

Name Discipline License State Firm/Organization

....................................................... ...................... ......................... .....................................................................

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....................................................... ...................... .......................... ..................................................................... ANSWER ALL QUESTIONS BELOW:

1. Do you have applications pending at the present time? no ...... yes ..... If so, where? .............................................

2. Have you previously applied for licensure in Nevada? no ....... yes ..... If so, when? ..............................................

3. Have you ever been Disciplined by a Board? no ....... yes ...... If yes, give details (attach sheet if needed):

………………………………………………………………………………………………………………………………………

4. Have you ever had a professional or vocational license suspended or revoked? no ......... yes ........

If yes, give details (attach sheet if needed):................................................................................................................

5. Have you ever applied for or received a professional or vocational license in any other field such as a contractor’s license or accountant’s license? no ....... yes .......

If yes , Where?........................... When?................. Type of License ....................................................................

6. Have you ever been denied a professional or vocational license? no ........ yes.......

If yes, Where?........................... When?.................. Type of License ......................................................................

7. Have you ever been convicted of a gross misdemeanor - or - a felony? no ....... yes ......…

If yes, give details and disposition ..........................................................................................................................…

8. Have you ever been known by any other name (maiden) or Social Security #? no....... yes...... If yes, please list:

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Affidavit (Applicant)....................................................................................., being first duly sworn, deposes and says, I, the applicant named in this application, have read the content hereof, and to the best of my knowledge and belief, the foregoing statements are true in substance and effect and are made in good faith. I, also, by this affidavit, do release the above-named references, employers or former employers from all liability to me for any damage whatsoever for giving any information they may have regarding me.

……................................................................................................ Signature of Applicant

Subscribed and sworn to before me this ....…................ day of ..................................................., 20................... ....................................................................................... Signature of Notary Public

Signed in the State of .........................................................

and County of ............……………........................................

Notary Seal

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