THE INSTUTUTION OF ENGINEERS, BANGLADESH HEADQUARTERS : RAMNA, DHAKA-100 Affix 2 attested recent P.P. size photo here Founded in 1948, Registered under Act XXI of 1860 Recognised by the Government of the People's Republic of Bangladesh Phone:9566336, 9559485, 9556112, Fax:880-02-9562447 E-mail: [email protected], [email protected]; Web:www.iebbd.org APPLICATION FORM FOR MEMBERSHIP (Fellow, Member, Associate Member) (All relevant spaces must be filled in) FOR OFFICIAL USE 1.0. PERSONAL INFORMTION Scroll No: 1.1. NAME Date of Receipt: 1.2. DATE OF BIRTH (on next birth date) Years 1.2.1. AGE D D M M Y 1.3. NATIONALITY Y Y Acknowledgement: Copies of Certificates Copies of Transcripts Y Photo Enclosed 1.2.2. PLACE OF BIRTH Y N Y N M AM Professional Record Enclosed Recommendation Applied for 1.4. MAILING ADDRESS (With postal code) F Name & Signature Evaluated by Membership Section Age 1.5. PERMANENT ADDRESS (With postal code) Education Experience Recommendation 1.6. PHONE OFFICE RESIDENCE MOBILE 1.7. GENDER Name & Signature E-mail MALE FEMALE (please tick as ) Chairman/Member Secretary/Member, Membership Committee 1.8. MEMBERSHIP APPLYING FOR Accepted 1.9. PRESENT IEB MEMBERSHIP NUMBER (if any) Rejected Name & Signature F/M 2.0. EDUCATION (enclose attested photocopies of certificates) EQUIVALENT LEVEL INSTITUTE BAOARD/UNIVERSITY YEAR OF PASSING DIV/CLASS GPA/CGPA SSC/Equivalent HSC/Equivalent B.Sc. Engg./Equivalent M.Sc/Ph.D/Equivalent Transcripts i) HSC/Diploma ii) B.Sc. Engg. 3.0. FIELD OF ENGINEERING : Please Tick in Division, Write Sub-Division(if any) Division Sub-Division Civil Mechanical Electrical Chemical Agricultural Computer Textile 4.0 PROFESSIONAL RECORD (If Necessary enclose separate page) PERIOD(Date) SL. NO. DESIGNATION FROM EMPLOYER BRIEF JOB DESCRIPTION TO 1 2 3 4 5 6 5.0 Please enclose attested copies of certificates of other professional bodies including Membership no.(if any) 1 2 6.0 DECLARATION : I declare that the information I have appended herewith and the documents enclosed are complete and correct. If enrolled, I shall conform to the constitution, bye-laws, rules and regulations of the Institution and to the code of Ethics. D D M M Y Y Y Y Signature of the applicant 7.0 RECOMMENDATION : I recommend him for the class of membership applied for: NAME (in block letters) MEMBERSHIP NO. SIGNATURE DATE Proposer Seconder I Seconder II Note (I) :Proposer and Seconder must be at least (i) Two Fellow and one Member for Fellowship (ii) One Fellow and two Members for Membership (iii)Two Members for Associate membership Note(II) :All necessary documents and photo must be attested by Proposer or Seconder Countersigned by Approved in the ............th Central Council Meeting held on ................................................................. Chairman Membership Committee Member Secretary 8.0 INFORMATION FOR APPLYING FOR MEMBERSHIP OF THE IEB Subscription Rate Category Others Entrance Fee(Tk.) Annual Subscription(Tk.) Diploma Fee(Tk.) Total (Tk.) Age in years (At least) Experience(Minimum) Fellow 400.00 600.00 100.00 1,100.00 35 10 years 15 years(if Non Member) Member 200.00 350.00 100.00 650.00 25 3 years (in Non Member) 2 years (if Associate Member) Associate Member 125.00 175.00 50.00 350.00 - Pl. Enclose attested copies 1.Photo PP Size (2copies) 2.Certificate: SSC, HSC, BSc. in Engg. B. Sc. Engg. Or Equivalent 3.Transcripts: HSC/Diploma. Engg. 4.Certificates of other Professional Bodies(if any)