Application for Licensing Examination

Instructions:
Provide all the information requested below. Mail copies of all licenses, certificates, and diplomas to the NIULPE Illinois Board. A current resume may be included at your option. First time examinees must mail to NIULPE a letter of recommendation from your most current supervisor, instructor or a NIULPE licensed Chief Engineer; describing your position, responsibilities and length of employment. Incomplete applications will be returned.

You may also download a printable version (pdf) of the Application for Licensing Examination. Acrobat Reader is needed to view the printable version. If necessary you can download the free Adobe Acrobat Reader. This link will take you directly to the Adobe site where you can download the PDF reader free.

Name
Date of Birth
Address
City
State Zip
Phone
Email
Social Security Number
NIULPE Class of License now Held
Last Year Renewed
Are you applying for reciprocity?	Yes No
Applying for Boiler Operators Trainee License?	Yes No

EMPLOYMENT List below information for up to the past 10-years of employment:
Employer
Employer's Address
Supervisor's Name
Supervisor's Phone#
Job Title
Description of Duties
Total Boiler HP
Total Refrigeration Tons
Pollution Equipment
Number of Employees Supervised (if applicable)
Dates of Employment	from to

Only 10 years of past employment is needed. If necessary continue below, if not, skip to "Education "
Employer
Employer's Address
Supervisor's Name
Supervisor's Phone#
Job Title
Description of Duties
Total Boiler HP
Total Refrigeration Tons
Pollution Equipment
Number of Employees Supervised (if applicable)
Dates of Employment	from to

Only 10 years of past employment is needed. If necessary continue below, if not, skip to "Education "
Employer
Employer's Address
Supervisor's Name
Supervisor's Phone#
Job Title
Description of Duties
Total Boiler HP
Total Refrigeration Tons
Pollution Equipment
Number of Employees Supervised (if applicable)
Dates of Employment	from to

Only 10 years of past employment is needed. If necessary continue below, if not, skip to "Education "
Employer
Employer's Address
Supervisor's Name
Supervisor's Phone#
Job Title
Description of Duties
Total Boiler HP
Total Refrigeration Tons
Pollution Equipment
Number of Employees Supervised (if applicable)
Dates of Employment	from to

EDUCATION List all Colleges, High Schools, Trade and/or Technical Schools Attended.
Name of School
Year(s) Attended	from to
Degree/Diploma

Name of School
Year(s) Attended	from to
Degree/Diploma

Name of School
Year(s) Attended	from to
Degree/Diploma

Attestation I hereby state that the information provided within this application, is true and correct to the best of my knowledge. I further acknowledge my understanding that submission of false information may serve as grounds for denial of license testing and/or revocation of an issued NIULPE license by the NIULPE Illinois Board of Examiners. By entering by name, I acknowledge that I have read the above statement and understand and agree to the terms and conditions listed therein.
Applicant's Name
Date

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The National Institute for the
Uniform Licensing of Power Engineers
910 Van Buren #220
Chicago, IL 60607
Phone: Chicago: (312) 850-0352
State Toll Free: (877) 4-NIULPE
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www.niulpeil.org

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