179 Architects and Engineers Qualifications

Expires: XX/XX/20XX
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0572-0059. The time required to complete this information collection is estimated to average 2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

"No further loan funds may be paid out under this program unless this report is completed and filed as required (7 U.S.C. 901 et. seq.). ''
1. NAME AND ADDRESS (Including Zip code )
U. S. DEPARTMENT OF AGRICULTURE
RURAL UTILITIES SERVICE

ARCHITECTS AND ENGINEERS QUALIFICATIONS
2. RUS PROJECT DESIGNATION

INSTRUCTIONS - Qualification information requested is to be furnished by responsible officer of engineering or architectural firm submitting qualifications to RUS
borrowers.

(if any)

4. ARE YOU OR ANY MEMBERS OF YOUR FIRM EMPLOYED
OR RETAINED BY ANY ORGANIZATION ENGAGED IN:
A CONSTRUCTING ELECTRIC OR TELEPHONE F'ACILI-

3. IF FIRM, LIST NAMES OF OFFICERS AND TITLES

YES

TIES?

NO

B. MANUFACTURING OR SELLING MATERIALS OR EQUIPYES
MENT THEREFOR?
NO

(if yes, give particulars on a separate sheet.)
5. LIST PROJECTS COMPLETED IN THE PAST THREE YEARS WHICH REQUIRED SERVICES SIMILAR TO THOSE YOU PROPOSE TO FURNISH:

6.

TYPE AND SCOPE OF SERVICES

LOCATION

NAME

STATE BRIEFLY THE FACILITIES AVAILABLE FOR USE ON THIS PROJECT.

ALSO LIST ASSOCIATES WHO MAY PERFORM SERVICES.

-

7. INDICATE TYPES OF SERVICES TO BE PERFORMED FOR RUS BORROWERS:
TRANSMISSION

DISTRIBUTION

POWER PLANTS

TELEPHONE

ARCHITECTURAL

8 LIST STATES OR AREAS IN WHICH SUCH SERVICES WILL BE PROVIDED:

DATE
RUS FORM

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SIGNATURE OF ARCHITECT OR ENGINEER

INDIVIDUAL QUALIFICATIONS SHOULD BE REPORTED ON REVERSE.

QUALIFICATIONS OF PRINCIPAL ENGINEERS OR ARCHITECTS
TITLE OF POSITION

NAME

AGE

NAME OF COLLEGE ATTENDED'

DATES ATTENDED
GRADUATED

MAJOR COURSE OF STUDY

DEGREES CONFERRED

YES

NO

OTHER COURSES OR TRAINING

LIST THE STATES IN WHICH YOU ARE ELIGIBLE TO PRACTICE ENGINEERING/ARCHITECTURE AND GIVE YOUR LICENSE NUMBERS

'

Give a statement of your past experience including dates and immediate supervisors listing present status first followed by statement
of earlier employment for the past 10 years. It is important to state the extent of responsibility and independent action which you have
had in these positions. This description of the technical nature of your duties is one of the most important parts of your qualifications.
We are interested in specific experience in the types of services you propose to perform such as design, preparation of plans and specifications, supervision of construction, and preparation of engineering studies and reports.
DATES OF EMPLOYMENT

PRESENT STATUS (If additional space is needed, use separate sheet.)
NAME OF EMPLOYER
(Month, year)
TO PRESENT TIME

FROM:
POSITION

IMMEDIATE SUPERVISOR

DATES OF EMPLOYMENT

(Month, year)
TO:
:

FROM:
POSITION

DATES OF EMPLOYMENT

(Month, year)

IMMEDIATE SUPERVISOR

NAME OF EMPLOYER

TO:

FROM:

IMMEDIATE SUPERVISOR

POSITION

RUS FORM

NAME OF EMPLOYER

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