"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 (if any) INSTRUCTIONS - Qualification information requested is to be furnished by responsible officer of engineering or architectural firm submitting qualifications to RUS

borrowers.

4. ARE YOU OR ANY MEMBERS OF YOUR FIRM EMPLOYED

OR RETAINED BY ANY ORGANIZATION ENGAGED IN:

3. IF FIRM, LIST NAMES OF OFFICERS AND TITLES

A CONSTRUCTING ELECTRIC OR TELEPHONE F'ACILITIES?

B. MANUFACTURING OR SELLING MATERIALS OR EQUIPMENT THEREFOR? YES N O

(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:

DATE SIGNATURE OF ARCHITECT OR ENGINEER

RUS FORM 179 REV 9-66 INDIVIDUAL QUALIFICATIONS SHOULD BE REPORTED ON REVERSE.

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.

YES N O
QUALIFICATIONS OF PRINCIPAL ENGINEERS OR ARCHITECTS

NAME TITLE OF POSITION AGE

NAME OF COLLEGE ATTENDED' DATES ATTENDED

MAJOR COURSE OF STUDY GRADUATED 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) NAME OF EMPLOYER

FROM: TO PRESENT TIME

POSITION IMMEDIATE SUPERVISOR

DATES OF EMPLOYMENT (Month, year) NAME OF EMPLOYER

TO:

:

FROM:

POSITION IMMEDIATE SUPERVISOR

DATES OF EMPLOYMENT (Month, year)

FROM: TO:

NAME OF EMPLOYER

POSITION IMMEDIATE SUPERVISOR

RUS FORM 179 REV 9-66 PACE 2