Professional Engineers - Form 5 - Record of Experience

	State of Maryland Department of Labor Maryland Board for Professional Engineers 1100 N. Eutaw St Baltimore, Maryland 21201 (410) 230-6322 (Baltimore area), (888) 218-5925 (toll free)

Professional Engineers - Form 5 - Record of Education/Experience

RECIPROCITY APPLICANT MUST COMPLETE THE FOLLOWING:

FULL NAME
	LAST	FIRST	MIDDLE

			YES NO
Name of College/University	Degree	Graduation Date
			YES NO
Name of College/University	Degree	Graduation Date

NOTE:

An official academic transcript must be sent to the Board's office directly from the college registrar. Transcripts marked "issued to student" will not be accepted.

Engage-
ment
Number

Date

Employment Record
(a)Name, Complete Location and Character of Business
(b)Kind of applicant's Engineering Work
(c)Degree of Responsibility

Engineering Experience Claimed

Name and complete Address of Person Familiar with Each Position

Mo.

Yr.

Time In
Years	Months

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

TOTAL TIME

TOTAL ALL SHEETS