ENGINEERING EXPERIENCE SUMMARY ALL INFORMATION MUST BE TYPED ON NO MORE THAN 3 PAGES. Page
APPLICANT NAME:
_
Dates of Work in Chronological Order (oldest to most recent)
List your Title, Company Name and a DETAILED description of your responsibilities for all jobs since completing high school. Include specific design/engineering tasks and type of calculations performed. ACCOUNT FOR ALL GAPS IN EMPLOYMENT (e.g. school, unemployed, traveling, etc.)
Do not overlap dates From To mo/yr mo/yr
04/2017
NOTE: Failure to submit sufficient detail of your experience may delay the processing of your application.
1. 2. 3. 4. 5.
Technician Experience Design Experience Project Engineering Engineering Management Other
All five columns must total 100% for each position. (2)
(3)
(4)
_ pages
Supervisor Name, Licensure Status, Title and Company
See Engineering Experience Summary Instructions. Enter each column as a percentage of experience for that position.
List your Title, Company Name and. a DETAILED description ... Include specific design/engineering tasks and. type of calculations ... application. 1. Technician ...
5. Other (Explain):. C. Disciplinary Action: Has disciplinary action ever been taken against this applicant? YES NO. If YES, give details of board action: Verified By: Title: Date: STATE BOARD SEAL. Page 1 of 1. EI and PE - Verification of Licensure
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