Fillable Professional Engineer Reference Form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Professional Engineer Reference Form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Professional Engineer Reference Form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 3 pages long and contains:

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  • 11 check-boxes
  • 61 other fields

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New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
P.O. Box 45015, Newark, New Jersey 07101
(973) 504-6460
Professional Engineer Reference Form
(Please print clearly.)
Name of RefeReNce Name of applicaNt
_________________________________________________ _____________________________________________
Lastname Firstname Middleinitial Lastname Firstname Middleinitial
_________________________________________________ _____________________________________________
Streetaddress Streetaddress
_________________________________________________ _____________________________________________
City State ZIPcode City State ZIPcode
Theapplicantforlicensure,whosenameandaddressappearabove,hassentyouthisrequestforareferencestatementand
hasreferredtoyouassomeonewhohaspersonalknowledgeofhis/hercharacterandprofessionalexperience.Also,attached
tothisformistheappropriatesectionoftheapplicant’s“DescriptionofExperience”foryourreviewandvalidation.Please
do not return this reference form without the attached “Description of Experience.”
Yourpromptcompletionandreturnofthisstatement,properlylledinandsignedintheappropriatelocation,willassistthe
StateBoardofProfessionalEngineersandLandSurveyors(theBoard)whenconsideringtheapplicantforlicensure.Your
responsetothisrequestwillbecondential.ThisstatementmustbereceivedintheBoardofceby____________________
iftheapplicantistobeconsideredforthenextscheduledexamination.
TheBoardisstatutorilyrequiredtoobtainevidenceoftheprofessionalexperienceandgoodcharacterofallthosewho
applyforlicensureasaprofessionalengineer.Statementsbyresponsiblepeoplewithactualknowledgeoftheexperience
andqualicationsoftheapplicantwillbeconsideredbytheBoardasmeetingthisprovisionofthelaw.
Thepracticeofprofessionalengineeringinvolvesrelationshipswiththepublicthatnecessitateahighdegreeofhonor,
integrityandprofessionalability.TheBoardtruststhatwhencompletingthisform,youfullyunderstandthatthepurposeof
thelawistoprotectthepublicfromthepracticeofengineeringbypeoplewhoarenotcompetenttoengageinsuchapractice.
Please return this statement directly to:
State Board of Professional Engineers and Land Surveyors
P.O. Box 45015
Newark, N.J. 07101
RE: __________________________
Forofceuseonly
You may be requested to substantiate any statements made herein.
StatemeNt of eNdoRSeR(This form should not be lled out in the presence of the applicant. Please print clearly.)
1. a.Howmanyyearshaveyouknowntheapplicantonapersonalbasis?__________________________________
b.Howmanyyearshaveyouknowntheapplicantinyourprofessionalcapacity?__________________________
2. Howwouldyoucharacterizetheapplicant’scharacterandpersonalreputation?
Excellent Good Unacceptable Notknown
If“Unacceptable,”pleaseexplain:_______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3.
Youaretheapplicant’s: Manager/Director DirectSupervisor Co-worker/Colleague Subordinate
Other___________________________________________________________________________________
4. Isyourknowledgeoftheapplicant’sengineeringexperiencebasedexclusivelyonyourrelationshipdescribedin
questionthree?
Yes No
If“No,”pleaseindicatethebasisofyourknowledge:________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
5. Pleasecommentontheapplicant’sabilitytoeffectivelycommunicate,bothverballyandinwriting,intheEnglish
language.
__________________________________________________________________________________________
__________________________________________________________________________________________
6. Pleasecommentontheapplicant’sknowledgeandapplicationofengineeringprinciples.____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7. Pleasecommentontheapplicant’sdevelopmentofengineeringjudgmentandworkaccuracy.________________
__________________________________________________________________________________________
__________________________________________________________________________________________
8. Pleasecommentontheapplicant’sabilitytoassumeresponsibilityanddirectpeople. ______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
9. Pleasecommentontheapplicant’sabilitytorecognizeandworkwithinhisorherownlimitations. ___________
__________________________________________________________________________________________
__________________________________________________________________________________________
10. Fromyourpersonalknowledge,pleaselistthetypeofworktheapplicanthasperformedandprovidethedetailsof
hisorherresponsibilities.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
11. Fromyourpersonalknowledge,forhowmanyyearshastheapplicantbeenengagedinengineering?__________
12. Pleaserefertotheattached“DescriptionofExperience.”Howmuchofthetimenotedinquestion11hasthe
applicantbeeninvolvedinoriginaldesignworkunderthedirectsupervisionofaprofessionalengineer?
_____________years.
13. Doyouconsiderthattheapplicanthasreachedaprofessionallevelinhisorherwork?
__________________________________________________________________________________________
__________________________________________________________________________________________
14. TheBoardwouldappreciateanyadditionalinformationthatyoumaywishtoprovide. _____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
15. Ifyouhaveanyreasontobelievethatlicensureoftheapplicantshouldbewithheldatthistime,pleasecomment
below.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
16. Ifyouarenotaprofessionalengineer,whatisyourbusinessorprofession? ______________________________
__________________________________________________________________________________________
17. Ifyouareaprofessionalengineer,pleaseprovideyourlicensenumber:________________________,_________

LicensenumberStateoflicensure

Your signature on this reference form indicates that you verify that the time and value of the applicant’s experience as
outlined on the attached “Description of Experience” is accurate to the best of your knowledge as of the date of your
signature.
 ____________________________________________________________________________________

SignatureDate
_______________________________________

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Professional Engineer Reference Form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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