WYOMING STATE BOARD OF REGISTRATION FOR

WYOMING STATE BOARD OF PROFESSIONAL ENGINEERS AND PROFESSIONAL LAND SURVEYORS

6920 Yellowtail Rd., Suite 100, Cheyenne, WY 82002

Telephone (307)777.6155/6156/Fax (307)777.3403

APPLICATION FOR FE EXAM AND ENGINEERING INTERN CERTIFICATION For University of Wyoming Students Only

Name (First Middle Last) Mr. Ms.

Telephone: Residence

*s Residence Address

*s Permanent Address

Birthplace

Date of Birth

Email (for confirmation of Application approval)

*please choose one as your preferred mailing address

Date of Application: UW ID: _W_______________ SSN: ____________________

Telephone: Permanent

City

State

Zip

City Age

State

Zip

Citizenship

A. EDUCATION

State in chronological order the name and location of each high school, college, university or technical school attended, the time spent at each and if graduated, the year of graduation; also list graduate work, evening school, correspondence school, etc.

Name and Location of Institution

Month & Year From/To

Date Graduated or Expected

Major

Degree Received or Expected

B. APPLICANT HISTORY

Have you ever been convicted or found guilty-regardless of adjudication-of a crime in any jurisdiction, or have you ever been found guilty by a military court-martial? (Do not include parking or speeding violations.) YES s NO If yes, please list date, jurisdiction (state and county), offense disposition, and all other relevant information on an attached

sheet.

C. EDUCATION ENDORSEMENT

If applicant's degree in engineering is the basis on which this application is filed and degree has not yet been received at the time this application is made, the following endorsement should be signed by the Dean of the College (or designee) from which the degree is anticipated:

I hereby recommend

be approved to take the Fundamentals of

Engineering Examination with the understanding that if he/she does not receive his/her degree they will not be issued a

certificate even though he/she passes the written examination given by the Board.

College Representative

Date

D. CODE OF ETHICS

I hereby subscribe to and agree to exemplify the following Code of Ethics: It shall be considered unprofessional and inconsistent with honorable and dignified bearing for any Professional Engineer:

1. To act for his client, or employer, in professional matters otherwise than as a faithful agent or trustee, or to accept any remuneration other than his stated recompense for services rendered.

2. To attempt to injure falsely or maliciously, directly or indirectly, the professional reputation, prospects or business of anyone.

3. To attempt to supplant another Engineer after definite steps have been taken toward his employment. 4. To compete with another Engineer for employment by the use of unethical practices. 5. To review the work of another Engineer for the same client, except with knowledge of such Engineer, or unless the

connection of such Engineer with the work has terminated. 6. To attempt to give or obtain technical services or assistance without fair and just compensation commensurate with

the services rendered. 7. To use the advantages of a salaried position to compete unfairly with other Engineers. 8. To act in any manner or engage in any practice which will tend to bring discredit to the honor or dignity of the

engineering profession.

E. AUTHORIZATION AND AUTHENTICITY

THE STATE OF County of

) ) SS )

I,

, being duly sworn, hereby affirm that the statements

and information contained in this application are true in every respect to the best of my knowledge. I hereby affirm that I

will make a good faith effort to prepare for and pass the FE Exam. Failure to do so may result in a delay of my

graduation. I also give the University of Wyoming the right to request my exam results from the Wyoming Board of

Professional Engineers and Professional Land Surveyors.

The foregoing instrument was acknowledged before me by

this

day of

, 20 .

Signature of Applicant

My Commission expires

Signature of Notary Public

Exam given 1st time:

Grade on examination: Exam given 2nd time:

Grade on examination:

(BOARD USE ONLY)

______________ ______________ ______________ ______________

Exam given 3rd time: Grade on examination: Registration Number: Date of Registration:

______________ ______________ ______________ ______________

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