COLORADO STATE BOARD OF REGISTRATION FOR
|Division of Registrations |Student Application for EI Enrollment |
|Office of Licensing–Professional Engineers |ENGINEER INTERN (EI) ENROLLMENT |
|(303) 894-7800 / FAX (303) 894-7693 |FUNDAMENTALS OF ENGINEERING |
|dora.state.co.us/registrations |(FE) EXAMINATION |
|Exam Administrator Website: |Exam Date: Saturday, October 30, 2010 |
*****your application must be typed*****
1. Submit your application and $30 application fee made payable to State of Colorado to your school by its deadline date
2. Pay $150 registration fee to NCEES online when you register for the exam
PART 1—APPLICANT INFORMATION
|Legal Last Name: |First: |Middle: |Suffix: |
|Previous Name(s): |
|Social Security Number*: |Date of Birth: |Gender: Male Female |
|(Do NOT list Student ID#) |(mm/dd/yyyy) | |
|Place of Birth (City and state, or foreign country): |
|Student Address: | |
|(PO Box or Street, City, State, Zip) | |
|Daytime Telephone Number: |E-mail Address: |
|Legal Residence Address: (if different | |
|from above) | |
|(PO Box or Street, City, State, Zip) | |
| | |Legal Residence Address: |
|SEND ALL CORRESPONDENCE TO: |Student Address: | |
PART 2—EDUCATION HISTORY
|List in chronological order the name and location of each high/preparatory school, college, university, or other educational institution attended. |
| |Years |Date Graduating | | |
|Name and Location of Institution |(from/to) |(mm/yyyy) |Degree |Degree Major |
| | |12/10 or 5/11 |BS |Type of Engg. (Civil, Elec, |
| | | | |Mech, etc.) |
| | | | | |
| | | | | |
PART 3—SCREENING QUESTIONS
|If your answer is YES to any of the following questions, you must provide a letter of explanation that includes date of offense, type of offense, penalty, and |
|whether all requirements were satisfied. |
|Have you ever been convicted of a felony under the laws of any jurisdiction in the United States? | YES NO |
|Have you ever been convicted of a misdemeanor drug or alcohol offense under the laws of any jurisdiction in the United States? | YES NO |
|Have you ever been convicted of misdemeanor fraud, misrepresentation or deceit offense under the laws of any jurisdiction in the United | YES NO |
|States? | |
ATTESTATION
In accordance with sections 18-8-503 and 18-8-501 (2) (A) (I), C.R.S., false statements made herein are punishable by law. I state under penalty of perjury as defined in section 18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge.
I understand that under the Colorado Engineering and Land Surveying Practice Acts, providing false information to the Board is grounds for denial, suspension or revocation of a Professional Engineer and/or a Professional Land Surveyor license.
Applicant Signature Date
-----------------------
Note: ONE check to “State of Colorado” is to be stapled to form. $150 check to NCEES is paid by credit card online, NOT by check.
Application MUST be typed. Handwritten applications will be rejected.
9-digit SSN
Must explicitly answer these 3 questions by checking “yes” or “no”. If “yes”, must supply full details in a letter.
Unsigned applications will be rejected.
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