FORM R
SUMMARY OF INDIVIDUAL’S EXPERIENCE

Applicant’s Information	
Individual’s Name:		
Is Applicant Licensed as a Professional Engineer in the State of New York?	Yes:		No:		
NYS Professional Engineering License Number:		
Education:		
Total Years of Experience:		

Provide project history totaling the minimum number of years of experience required by the job description. Add rows as needed.

For each project, provide:

•	Project Name: must include Contract Number, Project Title, and Project Location
•	Project Description: description of project, including any unique aspects or challenges
•	Project Owner: must be agency/owner (cannot be consultant or contractor)
•	Contact Information: must include Name, Phone, and Email of reference from Project Owner (cannot be consultant or contractor)
•	Project Cost Value: total value of the project
•	Title on Project: candidate’s title on the project
•	Individual’s Duties & Responsibilities: description of candidate’s specific responsibilities on the project
•	Individual’s State Date on Project: must be in Month/Year format
•	Individual’s End Date on Project: must be on Month/Year format
•	Individual’s Total Time on Project: identify the total time the candidate spent on the project (start date to end date, in months)
•	% of time on Qualifying activities: identify the percentage of time spent performing duties (cannot be more than 100% in any given time period)
•	Qualifying Time: calculate the percentage of time spent performing duties by the total time to determine the number of qualifying months. Example: Total Time on project is 12 months (1st box) with 50% of time spent on qualifying activities (2nd box) equals 6 months of qualifying time (3rd box).

All Qualifying Time provided must total the minimum number of years of experience required in the job description!

Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months) 		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Project Name:		
Project Description:		
Project Owner:		
Contact Information:		
Project Cost Value		
Title on Project:		
Individual’s Duties & Responsibilities:		
Individual’s Start Date on Project:
MM/YY		Individual’s End Date on Project:
MM/YY		
Individual’s Total Time on Project:
(in months)		% of time spent on Qualifying activities		Qualifying time: 
(in months)		
	
Explain gaps in chronology for qualifying experience: