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pdfOMB No. 0572-0059
Expires: xx/xx/20xx
View Burden Statement
"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
INSTRUCTIONS - Qualification information requested is to be furnished by
responsible officer of engineering or architectural firm submitting qualifications to
RUS borrowers.
3. IF FIRM, LIST NAMES OF OFFICERS AND TITLES
2. RUS PROJECT DESIGNATION (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'ACILITIES?
Yes
No
B. MANUFACTURING OR SELLING MATERIALS OR EQUIPMENT THEREFOR?
Yes
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:
NAME
LOCATION
TYPE AND SCOPE OF SERVICES
6. 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:
DISTRIBUTION
TRANSMISSION
POWER PLANTS
TELEPHONE
ARCHITECTURAL
8 LIST STATES OR AREAS IN WHICH SUCH SERVICES WILL BE PROVIDED:
SIGNATURE OF ARCHITECT OR ENGINEER
DATE
RUS FORM 179
REV 5-24
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.
PRESENT STATUS ( If additional space is needed, use separate sheet.)
DATES OF EMPLOYMENT
(Month, year)
FROM:
TO PRESENT TIME
POSITION:
IMMEDIATE SUPERVISOR:
DATES OF EMPLOYMENT
FROM:
(Month, year)
TO:
POSITION:
NAME OF EMPLOYER:
IMMEDIATE SUPERVISOR:
DATES OF EMPLOYMENT
FROM:
(Month, year)
POSITION:
RUS FORM 179
NAME OF EMPLOYER:
TO:
NAME OF EMPLOYER:
IMMEDIATE SUPERVISOR:
REV 5-24
PACE 2
File Type | application/pdf |
File Title | rus0179.ofm |
Author | MBrooks |
File Modified | 2024:10:16 14:03:33-04:00 |
File Created | 2024:10:16 14:03:33-04:00 |