Eng Experience Record

WORK EXPERIENCE RECORD 1
APEGA ID Number Date: (Enter as MM/DD/YY)
Applicant SURNAME Applicant FIRST NAME
Are you a professional

If yes, please provide: Association, Designation,
engineering technologist
Member#, Registration Date:
in any jurisdiction?
Employer Job Title
Country in which work was

If work was in Canada, indicate province or territory
performed
Start Date (mm/dd/yy) End Date (mm/dd/yy)
TOTAL MONTHS 0.0
If work was part-time, indicate approximate number of

Was this work part-time?
hours worked per week
Reference SURNAME Reference FIRST NAME
Reference Professional
Reference's professional relationship to you
Designation
If the Reference designation is "Other", please clarify.
If the Reference professional relationship to you is "Other", please clarify.
Reference Email Did the reference have supervision and control of the
work on this record?
SUMMARY OF ENGINEERING WORK:
Number of months of engineering work claimed at a professional level
Number of months of engineering work claimed at a technologist or technician level
Total number of months from Lines 16 and 17 must be equal to the Total number of months on Line 7.
DESCRIPTION of engineering work claimed at a professional level. Please enter all details below:
Note: For the "return" function (to begin a new line in an Excel cell), use "Alt" "Enter" on the keyboard.
DESCRIPTION of engineering work claimed at a technologist or technician level. Please enter all details below:
APEGA P.L. WER V.2 05/09/19 JT


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation


Employer Job Title

performed
TOTAL MONTHS 0.0

Designation

11 of 11
Applicant Surname Applicant First Name Applicant APEGA ID#
REFERENCE QUESTIONNAIRE
Please refer to the applicant's Work Experience Record and complete the non-shaded areas below where applicable.
The "Tab" key can be used to move through the required cells.
Reference If your Designation is 'Other',

Reference Name
Designation please enter it here:
Jurisdiction in which you are Your professional relationship

Your Member #
registered to applicant
If your professional relationship to applicant is "Other", please clarify:
Time period you are referencing (time period for which you can directly attest to and reference the work presented on the Work Experience Record):
From(mm/dd/yy) To(mm/dd/yy) Total months 0.0
Company at which work was Have you viewed the Work Experience Record, and is it accurate and valid for the time period
performed you are referencing? If your response is "No" please clarify directly below:
SA
Did you have direct supervision and control of the applicant's work which is on the Work Experience Record, for the time period you are referencing?
What percentage of the applicant's work was performed at a Professional Engineering Level?
M
What percentage of the applicant's work was performed at a Technologist or Technician Level?
Note: The above percentages must add up to 100%

PL
Does the applicant exhibit a good character and reputation?
Does the applicant understand and apply the principles of the Code of Ethics?
Has the applicant demonstrated an acceptable working knowledge of spoken and written English?
EO
Has the applicant become aware of the societal implications of their work?
Do you recommend that the applicant be registered as a professional licensee with APEGA?
If the answer is "No" to any of the above questions, please provide clarifications and comments below:
NL
Y
Any additional comments you would like to make:
I declare that, by entering my name below, I have read, understood, and have answered truthfully and completely
I declare that I am fully aware that any failure to disclose omissions or inaccuracies on this form may make me immediately subject to investigation by APEGA
and complaint to my current home association.
Reference Name: Today's date(mm/dd/yy):
APEGA P.L. REFQ V.2 05/09/19 JT

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WORK EXPERIENCE RECORD 1

APEGA ID Number Date: (Enter as MM/DD/YY)

Applicant SURNAME Applicant FIRST NAME

Are you a professional

Employer Job Title

Country in which work was

Start Date (mm/dd/yy) End Date (mm/dd/yy)

TOTAL MONTHS 0.0

If work was part-time, indicate approximate number of

Reference SURNAME Reference FIRST NAME

If the Reference designation is "Other", please clarify.

If the Reference professional relationship to you is "Other", please clarify.

SUMMARY OF ENGINEERING WORK:

Number of months of engineering work claimed at a professional level

Number of months of engineering work claimed at a technologist or technician level

APEGA P.L. WER V.2 05/09/19 JT

APEGA ID Number Date: (Enter as MM/DD/YY)

Applicant SURNAME Applicant FIRST NAME

Are you a professional

Employer Job Title

Country in which work was

Start Date (mm/dd/yy) End Date (mm/dd/yy)

TOTAL MONTHS 0.0

If work was part-time, indicate approximate number of

Reference SURNAME Reference FIRST NAME

If the Reference designation is "Other", please clarify.

If the Reference professional relationship to you is "Other", please clarify.

SUMMARY OF ENGINEERING WORK:

Number of months of engineering work claimed at a professional level

Number of months of engineering work claimed at a technologist or technician level

APEGA P.L. WER V.2 05/09/19 JT

APEGA ID Number Date: (Enter as MM/DD/YY)

Applicant SURNAME Applicant FIRST NAME

Are you a professional

Employer Job Title

Country in which work was

Start Date (mm/dd/yy) End Date (mm/dd/yy)

TOTAL MONTHS 0.0

If work was part-time, indicate approximate number of

Reference SURNAME Reference FIRST NAME

If the Reference designation is "Other", please clarify.

If the Reference professional relationship to you is "Other", please clarify.

SUMMARY OF ENGINEERING WORK:

Number of months of engineering work claimed at a professional level

Number of months of engineering work claimed at a technologist or technician level

APEGA P.L. WER V.2 05/09/19 JT

APEGA ID Number Date: (Enter as MM/DD/YY)

Applicant SURNAME Applicant FIRST NAME

Are you a professional

Employer Job Title

Country in which work was

Start Date (mm/dd/yy) End Date (mm/dd/yy)

TOTAL MONTHS 0.0

If work was part-time, indicate approximate number of

Reference SURNAME Reference FIRST NAME

If the Reference designation is "Other", please clarify.

If the Reference professional relationship to you is "Other", please clarify.

SUMMARY OF ENGINEERING WORK:

Number of months of engineering work claimed at a professional level

Number of months of engineering work claimed at a technologist or technician level

APEGA P.L. WER V.2 05/09/19 JT

APEGA ID Number Date: (Enter as MM/DD/YY)

Applicant SURNAME Applicant FIRST NAME