9643 Brookline Avenue Suite 121 • Baton Rouge, Louisiana 70809‐1433 • (225) 925‐6291 • Fax (225) 925‐6292 • www.lapels.com/ MODIFIED MAR 2018 Louisiana Professional Engineering and Land Surveying Board Application for Certification as an Engineer Intern INSTRUCTIONS NOTE: Applications are subject to revision and modification at any time. In order to ensure timely processing, please verify that you are submitting the most current version of our application form. • Read all of the instructions before you begin. • Much of this information may be included in your MY NCEES account. • If you do not have a MY NCEES account, you must provide all required documents. • Applications must be typed. Hand written applications are not acceptable. • Complete all required sections of the application; incomplete applications will not be processed. • This application is used for two (2) different categories relative to Engineer Intern certification. You must indicate one of these categories: A. Engineer Intern Certification after passing FE exam & obtaining BS degree B. Certified Engineer Intern from another jurisdiction (Comity) In addition to the application, please also submit the following (if it is not included in your MY NCEES account), which you will find under “Supporting Document Forms for Applications”: • Transcript Request Form (send to university, OR request EScripts addressed to [email protected]) TRANSCRIPT MUST BE ISSUED DIRECTLY TO LAPELS FROM THE UNIVERSITY. TRANSCRIPTS INCLUDED WITH APPLICATION ARE NOT ACCEPTABLE. • Verification of Certification/ Examination IMPORTANT: If your only degree is an Engineering Technology degree, you are NOT eligible for PE licensure in Louisiana, and you should not submit an application. This is a state law which neither the Board staff nor Board members may waive. We do not issue refunds for application fees.
Louisiana Professional Engineering and Land Surveying Board
Application for Certification as an Engineer Intern
INSTRUCTIONS
NOTE: Applications are subject to revision and modification at any time. In order to ensure timely processing, please verify that you are submitting the most current version of our application form.
• Read all of the instructions before you begin.• Much of this information may be included in your MY NCEES account.• If you do not have a MY NCEES account, you must provide all required
documents.• Applications must be typed. Hand written applications are not acceptable.• Complete all required sections of the application; incomplete applications will
not be processed.• This application is used for two (2) different categories relative to Engineer
Intern certification. You must indicate one of these categories:
A. Engineer Intern Certification after passing FE exam & obtaining BSdegree
B. Certified Engineer Intern from another jurisdiction (Comity)
In addition to the application, please also submit the following (if it is not included in your MY NCEES account), which you will find under “Supporting Document Forms for Applications”:
• Transcript Request Form (send to university, OR request EScripts addressed [email protected]) TRANSCRIPT MUST BE ISSUED DIRECTLY TO LAPELS FROM THE UNIVERSITY. TRANSCRIPTS INCLUDED WITH APPLICATION ARE NOT ACCEPTABLE.
• Verification of Certification/ Examination
IMPORTANT: If your only degree is an Engineering Technology degree, you are NOT eligible for PE licensure in Louisiana, and you should not submit an application. This is a state law which neither the Board staff nor Board members may waive. We do not issue refunds for application fees.
Section 1 ‐ Personal Information • Open the application and complete all fields; entering your full legal name and social
security number.Louisiana Revised Statute 37:23 requires that every application by an individual for aprofessional license, permit or certificate shall require the applicant’s social securitynumber. Disclosure of your social security number is mandatory for this purpose and forpurposes of establishing, modifying or enforcing family and child support obligations andlocating an individual who is under an obligation to pay family or child support under La.R.S.46:236.1.1, et seq. Failure to provide your social security number for these mandatorypurposes will result in the denial of your licensure, permit or certificate application.Disclosure of your social security number is voluntary for disclosure to other stateregulatory agencies, testing and examination vendors, law enforcement agencies, andother private federations and associations involved in professional regulation. Suchdisclosure is for identification purposes only. Your social security number will not bereleased for any other purpose not provided by law.
• Enter dates using this format: MM/DD/YYYY.• Do not leave any section blank. State ‘N/A’ where applicable.• Provide a phone number and email address where you can be reached during the day.
Section 2 – Education
• Complete this section listing all colleges and universities attended where a degree wasconferred.
The Board requires that all applicants with a non‐ABET or non‐engineering degrees must obtain a credential evaluation prior to applying to LAPELS. See box below for the approved evaluation service center. Evaluations from providers other than NCEES are not acceptable.
APPROVED CREDENTIAL SERVICE CENTERS NCEES Center for Evaluation
Section 3 – Violations • If you answer yes to any of the questions in this section, you will need to submit a detailed
description for each violation and you may be required to provide court documents.
Section 4 –Examination/ Certification in Louisiana or other jurisdictions
• If you took the FE exam in Louisiana – we can access your score on the LAPELS database;• If you have a MY NCEES Account, this information may be included;• If you took the FE exam in another jurisdiction, and you do not have a MY NCEES account,
you’ll need to contact that jurisdiction and ask that a verification of examination/certificationbe sent to the LAPELS office. Most jurisdictions send this information to us electronically.
• Here is the link to request a verification from another jurisdiction:http://ncees.org/supplemental/launch‐login/
Section 5 – Recommendation‐ • You must be recommended for certification by a licensed Professional Engineer.
Section 6 – Acknowledgment – – sign and date (digital signature is acceptable)
EXPERIENCE RECORD FORMS Required ONLY for foreign/Non‐ABET applicants, per Rule 901 (A) (3) See Instructions for Completing Experience Record Forms
Section 7 – Experience Record Summary Grand totals must be completed and correspond with all time on your Experience Record Forms
VERIFICATION OF EXPERIENCE FORMS (required ONLY for applicants submitting Experience Records) http://www.lapels.com/docs/Applications/Verification_Experience_with_Instructions_AR.pdf
• After completing the appropriate fields, ensure that the “From” and “To” dates, name, titleand present address of person most familiar with each engagement match the information onthe Experience Record forms. Send a Verification of Experience form and copy of ExperienceRecord which that person will verify, to each supervisor listed on the Experience Recordforms. Verification of Experience Forms should be returned to you in a signed/sealedenvelope and included with your application for submittal to LAPELS. These forms areconfidential and should not be opened by the applicant.
After you have completed the application you may submit the application one of two ways:
1. By mail to LAPELS, 9643 Brookline Avenue, Suite 121, Baton Rouge, LA 70809 with a check ormoney order in the amount of $20.00 made payable to LAPELS.
2. By e‐mail to [email protected] with a credit card authorization form in the amount of$20.00 application fee.
After you have completed the application, please mail it to LAPELS, 9643 Brookline Avenue, Suite 121, Baton Rouge, LA 70809. Make check or money order payable to LAPELS.
It is your responsibility to submit a complete and accurate application, which includes the required/nonrefundable application fee of $20 (check or money order only). Upon receipt of your application, the Board applications staff will process your paperwork and communicate with you concerning any missing or incomplete documentation. Once your application is complete, it will be forwarded to a Board reviewing committee. Processing time for a complete application is 6‐8 weeks.
A letter will be mailed to you from LAPELS informing you of approval or disapproval.
Credential Evaluation(only for foreign/NON ABET degrees)
Verification of Fundamentals Exam(see instructions for obtaining this information)
Experience Record Forms(only for foreign/non-ABET degrees)
Verification of Experience Forms(only for foreign/non-ABET degrees)
Credit Card Authorization Form --if paying by Credit Card, click the "Submit" button below to transmit this document packageCheck or Money Order: --if paying by Check or Money Order, print out entire packet and mail to:
LAPELS 9643 Brookline Avenue, Suite 121 Baton Rouge, LA 70809
Comments:
Please check oneApplicant Notes
*If you are unable to create an electronic signature after the form is complete, please print, sign and email the form to [email protected] completion, click the submit button below and the form will be transmitted via email to
A. Engineer Intern Certification after passing FE exam & obtaining BS degreeB. Certified Engineer Intern from another jurisdiction (Comity)
A $20 non-refundable fee is to be submitted with this application. Make check or money order payable to LAPELS. ALL INFORMATION MUST BE TYPED. Hand written applications are not acceptable.
Date of application: My NCEES #
1. PERSONAL INFORMATION – all applicants must complete this section
SSN: Name: Last Name First Name Middle/Maiden Name Suffix
Address:
City: State: Zip: Country:
Work Phone: Home Phone:
Cell Phone: E-Mail:
Date of Birth: City of Birth:
State of Birth:
Country of Birth:
Gender: US Citizen? Yes No If no, what country? Visa/Green Card #:
2. EDUCATIONList in chronological order, the name and location of each college or university where a degree was conferred, the time spent at each institution, and if graduated, the date of graduation, the degree received and the major as shown on your transcript. See the instructions concerning submitting transcripts and if applicable, a credential evaluation. Transcripts must be submitted by your college/university directly to LAPELS
Institution Information Years Attended Graduation Date
3. VIOLATIONS – all applicants must complete this sectionHave you ever been convicted of a felony or of a crime of moral turpitude or entered a plea of guilty or nolo contendere to a felony charge or to a crime of moral turpitude under the laws of the United States or any state, territory or district of the United States?
Mark one: Yes No Have you ever been convicted of any crime or entered a plea of guilty or nolo contendere to any criminal charge an element of which is fraud or which arises out of your practice of engineering or land surveying? Mark one: Yes No
Have you ever been convicted of any civil or criminal violation of, or entered a plea of guilty or nolo contendere to any criminal charge under, the Louisiana Campaign Finance Disclosure Act or any other campaign finance and/or practices laws of the State of Louisiana, the United States, or any state, territory or district of the United States? Mark one: Yes No
If you have a license, permit or certificate to practice engineering or land surveying, has it ever been the subject of a disciplinary action by any state, territory or district of the United States? Mark one: Yes No N/A
Are you an owner, partner, officer, director, managing member or supervising professional of a firm whose license, permit or certificate to practice engineering or land surveying has ever been the subject of a disciplinary action by any state, territory or district of the United States? Mark one: Yes No
If the answer to any of these questions is “Yes”, provide the date and the pertinent facts of the case or proceeding including its final disposition. Attach additional pages as necessary.
4. EXAMINATION VERIFICATION IN LOUISIANA OR OTHER JURISDICTIONSJurisdiction Date
5. RECOMMENDATION: You must be recommended for certification by a Professional Engineer with a current license. This is to certify that this applicant named is a person who I believe is of good character and repute, and I hereby recommend this applicant to the Louisiana Professional Engineering and Land Surveying Board as entirely worthy of consideration for certification as an Engineer Intern in the State of Louisiana. Signature of Professional Engineer: PE No.
Print name of Professional Engineer: Jurisdiction Licensed:
Area Code & Phone: Date:
6. ACKNOWLEDGMENT I, the applicant named in this application, have read the contents hereof, and to the best of my knowledge, information and belief the statements and information in this application are true and correct in substance and effect and are made in good faith. I have not omitted any information requested in this application. I am aware that such an omission or untrue response may constitute fraud or deceit, material misstatement, perjury or the giving of false or forged evidence under Louisiana Revised Statutes 37:698 and 37:700. I understand and agree that any responses verifying my education, personal references, and experience shall be considered privileged and confidential and that this information was not reviewed by me nor will it be available for my inspection or review in the future. I have read the Rules for Professional Engineers and Land Surveyors (LAC Title 46, Part LXI), and I agree to conduct my professional affairs in accordance with these rules.
Signature of Applicant:
For LAPELS office use only – do not write in this area
Credit Card Authorization Form (All information will remain confidential)
Cardholder Name:
Name on Application: (if different from credit card holder)
Billing Address:
American Express
Phone Number: Email:
Credit Card Type: Visa MasterCard Discover
Credit Card Number:
Expiration Date: (MM/YY)
Card Identification Number (last 3 digits on the back of the credit card):
Amount to Charge (USD): $
I authorize LAPELS to charge the agreed amount listed above to my credit card provided herein. I
agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.
Cardholder: Print Name, Sign and Date below
Signature:
Print Name:
Date: OFFICE USE ONLY
Application Type ________________
Confirmation Number __________________
INSTRUCTIONS FOR COMPLETING EXPERIENCE RECORD FORMS
Experience Records should be submitted ONLY by applicants with a foreign/Non-ABET degree, who are required to have 4 years of experience in order to be certified as an Engineer Intern in Louisiana (see Rule 901 (A) (3).
ALL TIME SINCE GRADUATION WITH BS DEGREE MUST BE DOCUMENTED ON AN EXPERIENCE RECORD FORM. You must include military, illness, unemployment or time spent completing an additional college degree, etc., on an Experience Record form. Time gaps will result in an incomplete application. The chart below is an example of the 8 column Experience Record form. The instructions below indicate how to complete the information in each of the columns.
1st column: Record number (start with first employment – end with current employment) 2nd column: Start date & end date for this record. The ending date for your current employer should be the same month & year as the application date. Dates must be reflected in “mm/yyyy” format. “Current” and/or “present” are not acceptable timeframes. 3rd column:
a. Position titleb. Company namec. Detailed description of experience (see paragraph below)*. Indicate character, magnitude & complexity of your work, yourduties & degree of responsibility. When describing experience, refer to Chapter 15, specifically Rules 1515, 1517 and 1519.Inadequate descriptions will delay the review process. Click here for additional information regarding the description of yourexperience.d. Name, title and present address of the supervisor or person most familiar with this engagement.
4th through 8th columns: List amount of time for this experience record in years & months, in the appropriate category.
*Applicant must comply with LAPELS Rule §1527 Supervision by Licensed Professional:A. Engineering. Experience should be gained under the supervision of a professional engineer holding a valid license to engage in thepractice of engineering issued to him/her by proper authority of a state, territory, or possession of the United States, or the District ofColumbia, or, if not, an explanation shall be made showing why the experience should be considered acceptable.(You may add an explanation to the Experience Record form or include a separate note.)
EXPERIENCE RECORD EXAMPLE
Name (Last, First): Doe, John
1
(1)
01/1999 04/2013
(2)
a. Position title
b. Company Name
c. Description of experience
(3)
d. Supervisor Name, Title, & current address
Times of each employment category (years and months)
(4) (5) (6) (7) (8)
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Begin listing your experience on the forms following this page, starting with your first employment. Use the TAB key to move between shaded fields. Click here for additional pages, if necessary. Remember, you must document all time subsequent to your graduation: military, illness, unemployment or time spent completing an additional college degree, etc. Once you have completed all of your experience, tally the time for each category in the box on the last page. These totals must be completed and correspond with all time on your experience records.
Once you have completed all of your experience, tally the time for each category in the box below. These totals must be completed and correspond with all time on your experience records.
7. EXPERIENCE RECORD SUMMARY
Name (Last, First):
Times of each employment category (years and months)
(4) (5) (6) (7) (8)
Non
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Engi
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GRAND TOTALS OF ALL EXPERIENCE: (These fields must be completed) ⇒
