APPLICANT: Complete page 1 and insert your name on the top of page 2. APPLICANT NAME AS IT APPEARS IN BOARD RECORDS: Mailing Address:
Company Name: PO Box, Street: City, State, Zip:
Daytime Telephone Number: (
)
E-mail Address:
REFERENCE NAME:
Dates of Work
From mo/yr
To mo/yr
List your Title, Company Name, and a DETAILED description of your job responsibilities since your license has expired indicative of your competency to practice.
This must be the same description of the engagement from the Architecture Experience Summary Form.
Name of Reference Verifying Experience, Licensure Status, Title and Company
APPLICANT: Provide this completed page 1, and page 2 with your name at the top, to your reference to fill out. Completed pages 1 and 2 must remain in the sealed and signed envelope as returned to you by your reference and included with your application. Architecture Experience Verification—Reinstatement
Page 1 of 2
10/2012
REFERENCE: Review the Applicant’s description on page 1 and answer the questions below. • Do not complete this form in the Applicant’s presence––the information you provide is confidential. • After completing the page below, place both pages of this form in a business size envelope. • Seal the envelope and sign your name across the flap on the backside of the envelope. • Return the sealed envelope directly to the applicant—do not send it to the Board Office. • Note that the Applicant will only get credit for this experience if this form is completely filled out and it is received from the Applicant in the original, sealed envelope that you have personally signed on the back. 1. 2. 3.
Do you concur with the description of experience, including dates, and duties? YES NO My business or profession is: My professional relationship to the applicant is/has been: Employer Supervisor Co-Worker Associate Reviewed Work Other: 4. Are you related to this Applicant by blood, marriage, or adoption? YES* NO 5. I am a licensed architect in the state(s) of: License Number: From: To: 6. I have known the Applicant for: (years/months) / / / 7. My appraisal as to how this Applicant has performed regarding skills, knowledge, and responsibility appropriate for a licensed Satisfactory Not Satisfactory Do Not Know Architect is: 8. Do you consider the Applicant technically qualified to be a licensed Architect? YES NO* 9. I have personally seen and reviewed the Applicant’s Work: YES NO 10. My appraisal of the Applicant’s performance is: FACTOR SATISFACTORY UNSATISFACTORY DO NOT KNOW Technical Competence Judgment Professional Integrity/Ethics Project Communications Independent Decision Making Coordination of Project Staff Code/Regulatory Knowledge Responsible Charge Capability
/
* REMARKS: Explanation to starred responses above and/or comments about the Applicant’s qualifications:
Reference Name:
Title:
Reference Company Name: Reference Company Address:
P.O. Box, Street: City, State, Zip:
Daytime Telephone Number: (
)
E-mail Address:
In accordance with C.R.S. 18-8-503 and 18-8-501 (2) (a) (I), false statements made herein are punishable by law. I state under penalty of perjury as defined in C.R.S. 18-8-503, that the information contained on this form is true and correct to the best of my knowledge.
My business or profession is: 3. My professional relationship to the applicant is/has been: Employer Supervisor Co-Worker Associate Reviewed Work Other: 4.
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Try one of the apps below to open or edit this item. ARC - Verification of Licensure and or Exam History.pdf. ARC - Verification of Licensure and or Exam History.
the best of my knowledge. Reference Signature Date. Page 2 of 2. LSI and PLS - Experience Verification Form.pdf. LSI and PLS - Experience Verification Form.
Exceptions are made for foreign nationals not physically present in the United States and for non- immigrants in the United States on student visas who do not ...
The preceding lists (A and B) contain the most common documents which can be used to establish U.S. Citizenship or legal alien status. Whoops! There was a ...
current BLS and ACLS and/or PALS certification at all times. Continuing education certificates of completion. Complete the âAnesthesia/Sedation Administration ...
... years old submitting $49.00 dues. OR. I am at least 65 years old submitting $45.00 senior discount dues. My birthdate (required for senior dues: dd/mm/yyyy): ...
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If you submitted an application within the last year and were notified that you did not meet the requirements and you. are submitting an update, you do not need ...
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12-25-314(1)(a)(I)(B) Graduate with a four-year architecture or environmental design degree, or ... Degree Programs .... ARC - Licensing Requirements.pdf.
Jun 2, 2014 - developed according to the World Resources Institute (WRI)/World Business Council for Sustainable ... 2 | Page. Verification Scope & Assertions. The scope of this verification ... Renewable Energy Credits (REC) deductions.
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ABSTRACT. Verification of paper documents is an important part of checking a person's identity, authorization for access or simply establishing a trusted currency. Many documents such as passports or paper bills include holograms or other view-depend