State of Maryland Department of Labor, Licensing and Regulation
Maryland Board for Professional Engineers
500 N. Calvert St., Room 308
Baltimore, Maryland 21202
(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.