WORK EXPERIENCE RECORD DETAIL PE FORM FOUR

(To be completed by the Supervisor for each job)

You, as the reference, may request additional experience information from the applicant including the NCEES licensing requirements as contained in the NCEES Model Rules (on the Internet at http:// www.ncees.org/Documents/Public/Model%20Rules.pdf ). You must personally complete, sign, seal, and return this form to the applicant in the envelope provided to you by the applicant. 1. 2. 3. 4. 5. 6. My relation with the Applicant has been/is: Employer Supervisor Co-Worker* Reviewed Work* Yes Yes Associate* Not yet ready* No* Other*

Do you consider the Applicant technically qualified to be registered as a Professional Engineer? I have personally seen and reviewed the Applicant's plans, calculations and/or reports.

I have personal knowledge of his/her work experience from the date of ___________ to the date of_____________ Are you related to this Applicant by blood, marriage or adoption? Yes* No

I am a Professional Engineer legally authorized to practice in the branch of_____________________ Engineering. Initial Date of License_____________ Expiration of Current License____________ (month and year) or I am not a Professional E ngineer**

7.

Do you verify the applicant 's information on Form 3 of this application, including position title and employment dat es?

Yes

No

* Explain all responses marked w ith an asterisk (*) in this section. Also, include any additional information about The Applicant's engineering experience, capabilities or limitations. (Use additional sheets as needed.) If you and the applicant currently have different employers, please explain h ow you know of the applicants experience. ** All Supervisors who are not Licensed Professional Engineers are requested to fill FORM 5

1/3

WORK EXPERIENCE RECORD DETAIL PE FORM FOUR

(To be completed by the Supervisor for each job)
8. My appraisal of the applicant's engineering performance is:

FACTOR

SATISFACTORY

NOT YE T REA DY

COMMENTS

a) Technical Competency b) Engineering Judgments c) Professional d) Integrity/Ethics e) Independent Decision Making f) Project Communications

g) Code/Regulatory h) Knowledge i) j) Responsible Charge Capability

k) Coordination of P roject l) Support

2/3

WORK EXPERIENCE RECORD DETAIL PE FORM FOUR

(To be completed by the Supervisor for each job)
9. I certify under penalty of perjury that these statements are true and correct to the best of my knowledge and that I have per s onally examined the applicant 's work. Your Title _____________________________________________ Your Company Name _________________________________ Your Name_______________________________ Address __________________________________ Phone___________________________________

Signature___________________________ Date_____________

PLEASE STAMP OR SEAL FORM WITH YOUR PROFESSIONAL ENGINEER'S STAMP (IF APPLICABLE)

3/3