PURPOSE: This rule establishes the filing deadline for examination and registration as a landscape architect. , -_ (1) All applications for examination and registration as a landscape architect shall be filed with the executive director by the second Friday of March. Auth: section 327.609, RSMo (Cum. Supp. 1990). Original rule filed Feb. 15, 1991, effective July 8,1991.

Roy D. Blunt (11/29/91) CODEOFSTATEREGULATIONS Lcleta~ Of state

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4CSR196-ECONOMIC DEVELOPMENT

. ~ .1..* . . STATE OF MISSOURI LANDSCAPE ARCHITECTURAL COUNCIL APPLICATION FOR REGISTRATION ENERAL INFORMATION - PLEASE READ BEFORE PREPARING APPLICATION ALL INFORMATION ON THIS FORM MUST BE TYPEWRITTEN

For references ‘oward,ng letters. please use the landscape a,ch,tect form number in the upper right-hand corner Of the application along with the applicant’s name. GENERAL INFORMATION (Indicate mslllng address by checking NAME (LAST. FIRST, MIDDLE INITIAL)

RESIDENCE ADDRESS (STREET, CITY, STATE, ZIP CODE)

SlRTHPLACE (CITY AND STATE)

JSINESSIEMPLOYMENT DATA B”SlNESS NAME

BUSINESS ADDRESS (STREET 8 NUMBER. CITY, STATE, ZIP CODE)

C REGISTRATION IN OTHER STATES ,A”EYcJU TAKEN THE “NlFORM NATIONAL HOW MANY TIMES 1 II. 1 I EXAM’NAT’oN7 0 YES 0 NO IFYES ) I HOW M.&NY TIMES 4.&m “0” TAKEN THE PLANT MATERiALS c-’ 2 I EXAM’NAT’0N7 !, YES 0 NO IFYES )/ !low list all licenses/registration or cetiifvzations as a landscape architect DATE OF STATE REGISTRATION

I

. RECORD OF CHARGES, CONVICTIONS AND FINES IMPOSED ON APPLICANT HAVE you wm SEEN DENIED FK~~STRATION IN *~0Tt+zR STATE? IF YES. ,NDlCATE STATE NAME AT RIGHT 0 YES 0 NO

Ill 1 I HAVE YOU EVER HAD ANY COMPLAINTS FiLED AGAINST YOU IN ANOTHER STATE? I2 IF YES. ,NDlCATE STATE NAME AT RIGHT 0 YES 0 NO HAVEYOU EVER SEEN CON”lCTED OF A FELONY~ k IF YES, EXPLAlN (ATTACH ADDITIONAL SHEET IF NECESSARY) 0 YES 0 NO Division 1964andscape Architectural Council

one box below)

2 HOME TELEPHONE

I

1. 6. DATE OF BlRTH

I

DATE,S) TAKEN

I DATE(S) TAKEN

you currently hold. Please attach additlonal REGISTRATION NUMBER

I 1 STATE NAME

STATE NAME

APPLICATION NUMBER LA-

ATTACH

PHOTO

HERE

FOR UNE APPLICANTS ONLY

3 SOCIAL SECURlTY NUMBER

I

7 CiTiZENSHlP

I

9 BiJSlNESS TELEPHONE NUMBER

LOCAilON (CITY. STATE)

LOCAT1ON ,CITY. STATE)

Information if needed.

HOW REGISTERED

,WR,TrEN EXAM ORAL EXAM. REClPROCiTY GRANDFATHER. EXPERIENCE OTHER)

I Chapter P-Applications

1. IV. EDUCATIONAL NAME OF INSTITUTION/CITY&STATE HIGH SCHOOL

EDUCATION - LIST COLLEGE(S) OR CONTINUING

1 NOTE: Applicant must document are not acceptable. V. RELEVANT PROFESSIONAL Below list four persons Do not use relatives or council members.

,

1. VI. EXPERIENCE-RELATED List at least five

Roy D. Blunt , RECORD YEARS ATTENDED FROM TO

EDUCATION BEGINNING WITH MOST RECENT

proof of graduation in the form of a CERTIFIED TRANSCRIPT

REFERENCES

from whom you are requesting letters of reference. See instruction sheet

PROFESSIONAL

1. (5) professional landscape architectural projects, including location, dates, and description. PROJECT DATE LOCATION

(U/29/91) CODE OF STATE REGULATIONS 4 CSR 196-2

_) GRADUATION DATE AND DEGREE CONFERRED

OF GRADES. Photostatic copies /

for type of reference required.

/

DESCRIPTION

4CSR196-ECONOMIC DEVELOPMENT Division 1964andscape Architectural Council

!ELATED PROFESSIONAL EXPERIENCE CONTINUED PROJECT DATE LOCATION DESCRIPTION

L

1. 111. EXPERIENCE-RELATED OTHER

1111. MEMBERSHIP IN SOCIETIES, ASSOCIATIONS, INSTITUTES OR LICENSURE/REGISTRATION IN OTHER PROFESSIONZ ORGANIZATION DESCRIPTION NAME OF ORGANIZATION LOCATION MEMBER SINCE OFFICES HELD / / I /

c

1. X. AFFIDAVIT ‘ENALTY STATEMENT solemnly swear that all statements contained in this application are true to the best of my knowledge and belief. Any false ;tatements or misrepresentations can result in revocation of registration. 0 NOT WRITE ON THIS PAGE - FOR OFFICE USE ONLY ‘PLICANT NAME

   ITEM

PPLICATION EFERENCE LETTER A, ARCH, PE. SUPR. EFERENCE LETTER 4, ARCH, PE. SUPR. EFERENCE LETTER A, ARCH, PE. SUPR. EFERENCE LETTER A, ARCH, PE, SUPR CHOOL TRANSCRIPTS

IRTH CERTIFICATE

C LARB CERTIFICATE

S’ 1 B u NE TEST RESULTS

I.4 0 PLANT MATERIALS R ECIPROCITY LI ICENSE/REGISTRATION L, 4 IN TRAINING L, A STUDENT A CCREDITED LA PROGRAM A DDITIONAL PROBLEMS/COMMENTS

c OUNCIL RECOMMENDATION C 3 APPROVED

C 7 DENIED D/

MO

Roy D. Blunt (H/29/91) 4 CSR 196-2 ma

LA NUMBER

DATE DATE PROBLEMS/COMMENTS

RECEIVED PROCESSED

#

EXAM

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CHAlRPERSON S,GNAT”RE

b CO”NClL MEMBER SIGNATURE

m 4CSR196-ECONOMIC DEVELOPMENT