WORK EXPERIENCE RECORD DETAIL

FORM 3
(To be completed by Applicant for each job)
I, the Applicant, hereby demonstrate qualifying experience as required by NCEES.

1. Last Name*___________________ First Name*_______________________ Middle Name(s)_________________________________

2.

Street Address______________________________ City__________ Governorate____________ Postal code____ Country*_________

3. Month/Day/Year of Birth*:_____/_____/_____
4. Email Address*________________________________
5. AUC Id Number* ______________________________
6.
Job Number

Start Date

Month

Year

End Date

Month

Year

Total Time Worked

Month

Year

Company name

Company Address

______________

______________________________________________________________________________

Supervisor's Name:
__________________________________________________________________________________________________________

Supervisor's Phone:
__________________________________________________________________________________________________________
Reference Name:
(If not supervisor)

__________________________________________________________________________________________________________

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WORK EXPERIENCE RECORD DETAIL

FORM 3
(To be completed by Applicant for each job)
7. Description of the tasks involved in performing the job:
a)

Level of Responsibility:

b)

Examples of Engineering Decisions Made:

c)

Examples of Projects involved

Signature of Applicant

_____________________________

Date
_______/______

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