Experience Certificate for Structural Design
I have completed my highest qualification Diploma/BE/B.Tech/M.E/M.Tech/Ph.D. in field of civil
engineering in mm/dd/yyyy. I have the following Projects Experience with me as per the prescribed details
in GCPCE Act and Notifications. I have total experience for the Structural Design from dd/mm/yyyy to
dd/mm/yyyy (Total number of years ) which is more/less than 15years and includes
__________ numbers of projects/buildings (Not load bearing structure) with____________Sq.M. Built-up
Area as shown in Table below. Separate Form 4 duly signed and stamped by the authorized person on a
letter pad of authorized person is also attached as per listed in Table. Total Experience Certificates as
structural design with Signed and stamped by the authorized person on a letter pad of authorized person are
also attached separately including the details of each projects.
Table: The details of Projects are given in Tabular form along with the Form no 4 status (yes/no).
Built-up Form-4*
Sr. Duration
Name of Project/Work Area in Location Attached
No From-To
Sq.M. -Yes/No
Structural Design
1
2
3
..
Structural Design: Total Project: ____________ and Built-up Area _______Sq.m
Note: *Form 4 duly signed and stamped by authorized person on a letter pad of authorized person for
each Project are attached separately. The Projects whose Built-up area is more than 140 Sq.M. as
per GCPCE Act Section 26 are only mention in the above table. (As Refered the GCPCE rules and
regulation for more details).
DECLARATION:
I am attaching Form no 4 for all the Projects as per the requirement. I am declaring here with that above
furnished details are true as best of my knowledge and the copies of Form No. 4 and Experience
Certificates are attached with duly signed and stamped by authorized person for each project listed above.
(Applicant Name and Signature)
Enclosures:
1. Copy of Total Experience Certificates duly signed by all authorized person on letter head 2.
Copy of Form No.4 for all projects as above
FORM 4
(Project Number:_______ Location: _________Built-up Area:_____sq.M)
EXPERIENCE CERTIFICATE TO BE SUBMITTED TO THE GUJARAT
COUNCIL OF PROFESSIONAL CIVIL ENGINEERS
Experience Certificate
1 Name of the applicant (Surname, First Name, :
Middle name)
2 Address of the applicant :
3 Educational qualifications of the applicant :
4 Name of work for which engineering design :
civil engineering (structural design) / civil
engineering (general) has been done
5 Name of owner :
6 Type of structure – RCC/Load bearing/other :
7 No. of Storey-G+ upper=Total :
8 Built up Area-G+ upper=Total :
9 Height of the Buildings-G+ upper=Total :
10 Location : :
District
Taluka
City / Village
Tikka No. / C.S. No.
R. S. No.
T. P. Scheme No.
F. P. No.
11 Local Authority who has granted permission for :
construction
Permission No.
Date
12 Completion Certificate No. :
Date
13 Scope of engineering design civil engineering :
(structural design) / civil engineering
(general)
14 Time duration during which engineering :
design civil engineering (structural design) /
civil engineering (general) is done
*Certificate to be given by the Authorized person on his letterhead.
Place: Seal &Signature of authorized signatory
Date:
