Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-8506
www.dpor.virginia.gov Board for Architects, Professional Engineers, Land Surveyors,
Certified Interior Designers and Landscape Architects
PROFESSIONAL ENGINEER EXPERIENCE VERIFICATION FORM
One Experience per Form
A416-0402EXP-vs1 Board for APELSCIDLA/PE EXP VER FORM
11/10/2021 Page 1 of 3
Instructions:
Applicant:
Complete Sections A then forward this form to a licensed professional engineer in the organization's engineering practice
where the experience was obtained. Each position must be listed on a separate Experience Verification Form and verified
with an original signature.
Experience Verifier:
Complete Sections B. Return this form to the applicant for inclusion in their application package. Your prompt
response is appreciated.
Section A (to be completed by applicant)
1.
Applicant's Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required) First (required) Middle Generation
Provide one of the following identification number:2.
Social Security Number or
Virginia DMV Control Number
State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued
by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.
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Enter the same identification number as used on examination, previous applications or licenses on file with the department.
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3.
Mailing Address (PO Box accepted)
City State Zip Code
4.
Employer (verifying experience on this form)
5.
Employer's Mailing Address
City State Zip Code
6. Job Description - Provide your job title(s) during your employment with the firm listed in question #4.
A.
Job Title
B.
Start Date End Date
-
MM/YY MM/YY
Time period in which the experience was obtained
C.
List the total number of Years/Months of Experience are you seeking approval for:
# of Months# of Years
D.
Employment Type:
If Part-time, on average, how many hours per week:
Fulltime Part-time (less than 30 hrs./week)
E. What is the total percentage of time devoted to the duties described in the box below:
F.
In the box provided on page 2; provide a description of the experience you are seeking approval for. Forward
this completed form (Section A&B) to the "Verifier" for validation.
A416-0402EXP-vs1 Board for APELSCIDLA/PE EXP VER FORM
11/10/2021 Page 2 of 3
Experience:
Refer to the Board regulation 18VAC10-20-240. Experience for examples of qualifying and non-qualifying engineering
experience. Complete the following table and give a detailed description of the type of experience, indicating whether you
had full or partial responsibility for the work and the complexity of the work.
The information provided in this table shall clearly describe the engineering work or research that you personally
performed.
Select the type(s) of "Qualified" experience used in this description:
Construction
MilitaryDesign
Co-Op/Internship
Industrial Graduate/Doctoral Degree
TeachingSales
General
Responsibility: % of work performed
Full or
Partial =
%
I certify, to the best of my knowledge, all information provided on this form is true and accurate.
Applicant's Signature Date
Page
of
A416-0402-vs1 Board for APELSCIDLA/PE EXP VER FORM
11/10/2021 Page 3 of 3
Section B (to be completed by the verifier) - Review Section A above and answer the following questions:
1.
Verifier's Name
2.
Verifier's Title
3.
Provide your license information:
Professional Engineer
State License No.
Exp. Date
4.
What is your business relationship to the applicant?
5.
During this time listed in question #6.B, were you a licensed professional engineer?
No
Yes
If no, how long have you been lincensed?
MM/DD/YYYY MM/DD/YYYY
To:
6. Check all services performed by the firm:
Architecture Surveyor Photogrammetry
Landscape ArchitectEngineering
Interior Design/Contract InteriorsLand Surveyor
Other
7.
To the best of your knowledge, did the applicant correctly describe his/her experience Section A, question #6.F.?
No
Yes
If no, provide a description of the type of professional engineering work or project(s) performed by the
applicant and the complexity of this work:
8.
Signature
Date
I certify, to the best of my knowledge, all information provided on this form is true and accurate.
