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  • Elicense Ohio Form 1011 EX - 1

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    psychotracker
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    This document is a supplemental engineering/surveying experience record submitted to the State Board of Registration for Professional Engineers and Surveyors. It provides information about an applicant's job title, employer, percentages of time spent on engineering and surveying work, descriptions of work performed, hours worked per week, and is certified by the applicant's supervisor.

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    eLicense Ohio Form 1011 EX_1

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    This document is a supplemental engineering/surveying experience record submitted to the State Board of Registration for Professional Engineers and Surveyors. It provides information about an applicant's job title, employer, percentages of time spent on engineering and surveying work, descriptions of work performed, hours worked per week, and is certified by the applicant's supervisor.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    656 views1 page

    Elicense Ohio Form 1011 EX - 1

    Uploaded by

    psychotracker
    This document is a supplemental engineering/surveying experience record submitted to the State Board of Registration for Professional Engineers and Surveyors. It provides information about an applicant's job title, employer, percentages of time spent on engineering and surveying work, descriptions of work performed, hours worked per week, and is certified by the applicant's supervisor.

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    © All Rights Reserved
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    of 1

    S TATE BOARD OF REGISTRATION FOR P ROFESSIONAL ENGINEERS AND S URVEYORS

    PES 1011-EX

    SUPPLEMENTAL ENGINEERING/SURVEYING EXPERIENCE RECORD


    PLEASE ONLY INCLUDE ONE PLACE OF EMPLOYMENT PER PAGE. YOU MAY UPLOAD AS MANY PAGES AS NECESSARY.

    APPLICANT’S NAME .
    DATES OF PE/PS SUPERVISION FROM . TO . TOTAL MONTHS .

    PERCENTAGE APPLICANT’S JOB TITLE EMPLOYER & LOCATION


    (%) OF TIME
    ENGINEERING . .
    DESCRIPTION OF ENGINEERING/SURVEYING PERFORMED:
    . .

    SURVEYING

    NON-ENG/SUR

    HOURS
    WORKED PER
    WEEK

    I CERTIFY THE ABOVE ENGINEERING/SURVEYING EXPERIENCE RECORD IS TRUE AND CORRECT TO THE BEST OF
    MY KNOWLEDGE AND SUBMITTED IN ACCORDANCE WITH OHIO REVISED CODE 4733 AND OHIO ADMINISTRATIVE
    CODE 4733.

    SUPERVISOR’S NAME SUPERVISOR’S SIGNATURE


    . .
    PE/PS REGISTRATION NUMBER/STATE DATE
    . .
    EMAIL PHONE NUMBER

    TOTAL EXPERIENCE ON THIS PAGE ENGINEERING . NON-


    ENGINEERING .
    SURVEYING . NON-
    SURVEYING

    PES 1011-EX (REV 04/2018)

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