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 5 - Record of Education/Experience

RECIPROCITY APPLICANT MUST COMPLETE THE FOLLOWING:


FULL NAME 
LASTFIRSTMIDDLE

    
checkbox YES  checkbox NO
Name of College/University Degree Graduation Date   
    
checkbox YES  checkbox 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
1 From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
TOTAL TIME 
TOTAL ALL SHEETS