Professional Engineers - Form 3 - Verification of Licensure

	State of Maryland Department of Labor Maryland Board for Professional Engineers 100 S. Charles St, Tower 1, 3rd Floor Baltimore, Maryland 21201 (410) 230-6322 (Baltimore area), (888) 218-5925 (toll free)

Professional Engineers - Form 3 - Verification of Licensure

I. APPLICANT MUST COMPLETE THIS SECTION:

BOARD OF PRIOR LICENSURE

STATE BOARD

ADDRESS


(NAME OF APPLICANT)


(STREET ADDRESS)


(CITY)	(STREET)	(ZIP)

Social Security No.

REQUIRED BY LAW

II. THE ABOVE NAMED PERSON WAS LICENSED AS:

LICENSE
NUMBER

DATE
ISSUED

VALID
UNTIL

DATE
APPLIED

PROFESSIONAL ENGINEER

ENGINEER-IN-TRAINING
(passed FE)

III. THIS LICENSURE WAS BASED UPON:

1. WRITTEN EXAMINATION: hrs. P&P hrs. OTHER
(EXPLAIN ON OTHER SIDE)

NO  YES hrs. FE (EIT) Date (Mo/Yr) FE

2. ORAL EXAMINATION: hrs. P&P

NO  YES DISCIPLINE EXAMINED IN:

3. COMITY WITH: (1)  (2)

4. EDUCATION AND EXPERIENCE: Were your state's requirements equal to, or more demanding at the time this person became licensed than Maryland's requirements which, from June 1,1967 to present, have been:

EDUCATION EXPERIENCE

None and 12 years of which 5 years were in responsible charge

OR

Non-accredited 4 year engineering degree and 8 years

OR

EAC/ABET accredited engineering degree and 4 years

NO

YES

If the applicant was licensed with your Board prior to June 1, 1967, please list the requirements in effect at that time on the second page.

BY: (BOARD SEAL)

TITLE:

DATE:

NOTE TO APPLICANTS: Include a postage paid, addressed envelope for return to Maryland Board.

III. THIS LICENSURE WAS BASED UPON:
1.	WRITTEN EXAMINATION:	hrs. P&P	hrs. OTHER (EXPLAIN ON OTHER SIDE)
	NO YES	hrs. FE (EIT)	Date (Mo/Yr) FE
2.	ORAL EXAMINATION:	hrs. P&P
	NO YES	DISCIPLINE EXAMINED IN:
3.	COMITY WITH:	(1) (2)
4.	EDUCATION AND EXPERIENCE: Were your state's requirements equal to, or more demanding at the time this person became licensed than Maryland's requirements which, from June 1,1967 to present, have been: