STATE OF MARYLAND
DEPARTMENT OF LABOR, LICENSING AND REGULATION
STATE BOARD FOR PROFESSIONAL ENGINEERS
500 N. CALVERT STREET, ROOM 308, BALTIMORE, MD. 21202-3651
410-230-6260/FAX 410-962-8483
APPLICATION FOR PROFESSIONAL ENGINEER LICENSURE BY EXAMINATION
APPLICATION FEE: $50.00 (non-refundable)
DEADLINES ARE FINAL. POSTMARKS ARE NOT ACCEPTABLESEE INSTRUCTIONS FOR DEADLINES and EXAMINATION DATES.
Application is filed under the subsection checked: (see directions)
14-305(b) 14-305(c) 14-305(d)
1. PERSONAL DATA.
Name:
LAST / FIRST / MIDDLE or Indicate (NONE)
LAST NAME ON TRANSCRIPT, IF DIFFERENT
Address:
(Street) / (Apt., Suite No.)
(City) / (State) / (ZIP)
(non-US Country)
Telephone: Day / Evening / E-Mail
Social Security Number (SSN) / If you do not have a SSN, contact the Board's office.
(Required By State Law)
Date of Birth / Place of Birth
My major field of engineering is / Discipline I wish to be examined in:
Have you passed the Fundamentals of Engineering exam? / YES / State / Date
NO / If NO file under 14-305(d) ONLY.
Have you previously applied for this examination in Maryland? YES NO
If YES, when: / Was your application approved? / Denied?
If you are re-applying after three unsuccessful attempts and a two-year waiting period, check here.
2. CONDUCT QUESTIONS. All questions MUST be answered.
(a) Have you ever been convicted of a felony or misdemeanor in any State or Federal Court? YES NO
If you answered YES, submit a written explanation to the Board, along with a true test copy of the court documents.
(b) Have you ever had this type of application denied by Maryland or any other jurisdiction? YES NO
If you answered YES, submit a written explanation to the Board.
Page 1 of 3 - Form 1-PE
3. EDUCATION.
Name of College or University / Degree / Graduation DateName of College or University / Degree / Graduation Date
NOTE: An official academic transcript must be sent to the Board's office directly from the college Registrar's office. Transcripts marked "issued to student" will not be accepted. Electronic transcripts will be accepted if sent by secure service.
Foreign Degree applicants: For each unapproved institution not located in the U.S. (with the exception of certain Washington Accord schools), you must provide an official course by course evaluation sent directly from the evaluation company to the Board’s office. See www.ncees.org or www.naces.org for a list of evaluation companies. The Board will only accept evaluations from companies that obtain transcripts directly from the institution.
4. EXPERIENCE.
Begin with EARLIEST employment, for each separate employment, identify each person from whom you will seek an endorsement. In general, your endorser should be the person who is/was the immediate supervisor of your work. If you are unable to obtain a supervisor’s endorsement, select another person with whom you worked who is sufficiently knowledgeable about your work to attest to the accuracy of your experience description. If part of your experience results from self-employment (e.g. as a licensee in another state), endorsement can be from a responsible subordinate or from a client for whom you provided professional services. The RPE numbers below must correspond to the numbers in the RPE boxes at the top right corner of the individual RPE Forms (see Forms 2 and 2A).
RPEFORM No. / Company or Employer Name
(Enter earliest engagement first) / Name of Endorser
(If any) / Dates of Employment
Mo/Yr to Mo/Yr / Total
Time
Yrs/Mos
1.
2
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
TOTAL EXPERIENCE CLAIMED: YRS. MOS.
Page 2 of 3 - Form 1-PE
5. REFERENCES. Please submit information required below from at least five individuals unrelated to the applicant. At least three of such individuals must be professional engineers who have personal knowledge of the applicant's engineering experience, but are not listed as one of the endorsers in the experience section above.
Reference No. 1 - P.E. -Name:
Address:
City/State/Zip:
State of Licensure License No.
Signature: Date:
Reference No. 2 - P.E.
Name:
Address:
City/State/Zip:
State of Licensure License No.
Signature: Date:
Reference No. 3 - P.E.
Name:
Address:
City/State/Zip:
State of Licensure License No.
Signature: Date:
Reference No. 4 - Other
Name:
Address:
City/State/Zip:
Signature: Date:
Reference No. 5 - Other
Name:
Address:
City/State/Zip:
Signature: Date:
6. CERTIFICATION.
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I further authorize the release of any information contained within this document to an authorized representative of the Department of Labor, Licensing and Regulation for further investigation. I certify that I have paid all undisputed taxes and unemployment insurance contributions payable to the Comptroller or the Department of Labor, Licensing and Regulation or have provided for payment in a manner satisfactory to the unit responsible for collection.
Signature of Applicant ______DATE______
In accordance with Executive Order 01.01.1983-18, the Department of Labor, Licensing and Regulation is required to advise you as follows regarding the collecting of personal information: Personal Information requested by the licensing agency of the Department is necessary in determining your eligibility for licensure. Such personal information is also intended for use as an additional means of verifying the licensee's identity or to enable the agency to communicate, in a timely manner, with the licensee should the need arise. The licensee has a right to inspect his/her personal record and to amend or correct the personal data if necessary. Personal information is generally available for inspection by the public only in accordance with the Public Information Act. Personal information is not routinely shared with state, federal or local government agencies.
Page 3 of 3 - Form 1-PE
Form 2
STATE OF MARYLAND
DEPARTMENT OF LABOR, LICENSING AND REGULATION
STATE BOARD FOR PROFESSIONAL ENGINEERS
REPORT OF PROFESSIONAL EXPERIENCE (RPE)
INSTRUCTIONS TO APPLICANT: Forward this original RPE Form to your endorser. If your endorser is not a licensed Professional Engineer, you must include evidence of engineering experience with your application. Be sure the RPE number above corresponds with the appropriate RPE number and information on page 2 of Form 1.
SECTION 1: TO BE COMPLETED BY APPLICANT.Name:
LAST / FIRST / MIDDLE
Telephone (home) / (work) / - / -
Social Security Number
Experience described on the reverse side of this RPE form was obtained while employed by:
Firm or Organization Name:
Endorser's Name:
TIME PERIOD: Beginning / Ending / Full Time Part Time, / hrs/ per wk
I hereby certify that the work experience described on the reverse side of this RPE Form and the time claimed for that experience are true and accurate.
______
APPLICANT’S SIGNATURE / DATE
SECTION 2: TO BE COMPLETED BY ENDORSER
1. Read carefully the applicant's Report of Professional Experience and any continuation sheets.
2. Provide the requested information below and answer questions 1-3. Please type or print clearly.
3. SIGN THE ENDORSER'S AFFIDAVIT IN SECTION 4 AND AT THE BOTTOM OF EACH RPE CONTINUATION SHEET (Form 2a), IF ANY. If you disagree with any information provided by the applicant, please do not endorse the applicant's experience and provide a letter of explanation as to why you disagree with the type of work experience or length of work experience claimed by the applicant. Please be sure to identify the applicant by full name when providing the letter of explanation.
Endorser Name:
Current Address
STREET / CITY / STATE / ZIP
Daytime phone: / E-Mail:
Licensed Professional Engineer in State / License No
WITH RESPECT TO THE APPLICANT'S REPORT OF PROFESSIONAL EXPERIENCE AS DESCRIBED IN SECTION 3:
1. Does the description accurately reflect the work personally performed by the applicant? YES NO
2. Does the time claimed by the applicant for this experience accurately reflect the actual time? YES NO
3. IDENTIFY YOUR WORK RELATIONSHIP WITH THE APPLICANT AT THE TIME, i.e. PROJECT
ENGINEER, SUPERVISOR, ETC. IF NONE, EXPLAIN.
DO NOT RETURN THIS FORM TO THE APPLICANT. / SEND RPE FORM TO:
BOARD FOR PROFESSIONAL ENGINEERS
500 N. CALVERT ST, ROOM 308,
BALTIMORE, MD 21202
Page 1 of 2 - PE Form 2
SECTION 3: TO BE COMPLETED BY APPLICANT.
A. Briefly describe your general engineering duties during your employment with the firm named in Section 1.
B.
1. Describe, in separate listings, specific categories of engineering work you personally performed while employed by the firm named. Use specific assignments as examples and describe how these comply with the definition of "Practice Engineering" in the Instructions. 2. Indicate separately in the TIME column at the right, the time you spent on each.
2. Were you supervised by a P.E.? YES NO
If you need more than one endorser from a single firm, USE SEPARATE RPE FORMS FOR EACH ENDORSER. If you do not have sufficient space on this form to report the experience to be verified by a single endorser, use additional RPE Continuation Sheets (Form 2a). BOTH YOU AND YOUR ENDORSER MUST SIGN EVERY SHEET.
Indicate the number of extra RPE CONTINUATION SHEETS (Form 2a) for this endorser. If zero enter "0"TIME
Types of Engineering Work / YRS / MOS
TOTAL THIS SHEET
C. Describe briefly your personal level of responsibility or authority for the work described above. Explain any changes in your title resulting from promotions or other job changes during this period of employment.
SECTION 4: ENDORSER'S AFFIDAVIT (Also complete Section 2 on other side.)
I have read the applicant's Report of Professional Experience. I hereby certify that I am knowledgeable about, and qualified to attest to, the applicant's work and engineering ability and that, except as otherwise noted on the front of this form, or in attached correspondence, the work experience described by the applicant and the time claimed therefore are generally true and accurate.
Endorser's Signature Date
SEAL
ENDORSER'S PE License No. State:
Page 2 of 2 - PE Form 2
FORM 2A
STATE OF MARYLAND
DEPARTMENT OF LABOR, LICENSING AND REGULATION
STATE BOARD FOR PROFESSIONAL ENGINEERS
RPE CONTINUATION SHEET
NameLAST / FIRST / MIDDLE
Signature / - / -
SOCIAL SECURITY
CONTINUATION OF SECTION 3 B (FORM 2): / TIME
TO BE COMPLETED BY APPLICANT. / YRS / Months
TOTAL THIS SHEET
Total this endorser
* FINAL SHEET
SECTION 4 ENDORSER'S AFFIDAVIT:
I have read the applicant's Report of Professional Experience. I hereby certify that I am knowledgeable about, and qualified to attest to, the applicant's work and engineering ability and that, except as otherwise noted on the front of this form, or in attached correspondence, the work experience described by the applicant and the time claimed therefore are generally true and accurate.
Endorser's Signature
Page 1 of 1 - PE Form 2A
FORM 3
REQUEST FOR VERIFICATION OF LICENSURE
TO: Maryland State Board for Professional Engineers
500 N. Calvert Street . Room 308 Baltimore, Maryland 21202-3651
(410) 230-6010 • FAX: (410) 962-8483
APPLICANTS: INCLUDE POSTAGE PAID, ADDRESSED ENVELOPE WHEN FORWARDING TO ANOTHER STATE BOARD FOR RETURN TO ABOVE ADDRESS
BOARD OF PRIOR LICENSURE PERSONAL DATA (Completed by Licensee)
FROM:STATE BOARD / (NAME OF APPLICANT)
ADDRESS / (STREET ADDRESS)
(CITY) (STATE) (ZIP)
Social Security No.
STATE VERIFICATION INFORMATION (Completed by State Board Providing Verification)
THE ABOVE NAMED PERSON LICENSED:PROFESSIONAL ENGINEER / LICENSE
NUMBER / DATE ISSUED / VALID UNTIL
ENGINEER-IN-TRAINING(passed FE)
BASIS OF LICENSURE
1. WRITTEN EXAMINATION HOURS RESULTS NCEES EXAM EXAM DATE
(PASS/FAIL/GRADE) (MO-DAY-YR)
FE (EIT) ______YES NO ______
P&P (PE) ______YES NO ______
STATE SPECIFIC/OTHER ______YES NO ______
EXAMINATION OPTION (DISCIPLINE) ______
2. ORAL EXAMINATION PE______Hours FE______Hours
3. BY COMITY: FE (EIT) ACCEPTED FROM: ______(State)
P&P (PE) ACCEPTED FROM:______(State)
4. OTHER______
EDUCATION AND EXPERIENCE: Were your State's requirements equal to or more demanding at the time this person was licensed than Maryland which, from June 1, 1967 to present, have been: YES NO
EDUCATION EXPERIENCE
None 12 years, of which 5 were in responsible charge
Non-accredited 4 yr engineering degree 8 years
EAC/ABET accredited degree 4 years
IF Applicant was licensed prior to June, 1967, list requirements in effect at the time on the reverse side of form, or attach, and check
DISCIPLINARY QUESTIONS
1. Has any disciplinary action ever been taken against the applicant? YES NO
2. If so, has this disciplinary case been satisfied to the Board's requirements? YES NO If not, please note on back
BY:______Date:______
TITLE:______BOARD SEAL
Page 1 of 1 - PE Form 3
Form 4
STATE BOARD FOR PROFESSIONAL ENGINEERS
ENGINEERING CURRICULUM CHECKLIST
Complete the information below then read the delivery instructions at the bottom of this form.
YOUR NAME:Last / First / Middle
You MUST complete FORM 4 IF YOU HAVE:
1. A 4-year engineering degree from a college/university in the United States not EAC/ABECT approved;
2. A 4-year engineering technology degree (either approved or unapproved by TAC/ABET) from a college/university in the United States;
3. A degree from a foreign institution; or,
4. Any other degree
A. Name of College(s)/University(ies) / Degree / Graduation Date1.
2.
3.
4.
An engineering curriculum of 4 scholastic years or more should consist of at least:
1. 15 semester hours in mathematics, which shall include differential calculus, integral calculus, and differential equations
2. 15 semester hours of instruction in basic sciences, including general chemistry and general physics with calculus
3. 30 semester hours of instruction in engineering subjects which shall include a course, project, or thesis that focuses upon engineering design
4. 15 semester hours of instruction in advanced mathematics, basic science or engineering
The following sections are to be used to list courses in each of the four categories above.