PE Rev- 10

(For office use) THE INSTITUTION OF ENGINEERS (INDIA) 8, GOKHALE ROAD, KOLKATA 700 020 APPLICATION FOR PROFESSIONAL ENGINEER (FRESH/RENEWAL) PART I (To be filled by the applicant in his/her handwriting using black ink only) 1. Name in block letters : First Son/Daughter/Wife of Address in block letters Middle Last
Paste latest photograph

City in block letters State in block letters E-mail id : Date of Birth : Nationality : 2. Academic Qualifications: BE / B. Tech or Equivalent ME / M Tech or Equivalent Discipline Discipline/Specialisation University University ................................................................... Tele No (.........)............... d d m m y y y y Mobile No...............................

Pin

Each item to be signed by at least one sponsor after personal verification

Year of Passing Year of Passing

Ph D or Equivalent

Discipline/Subject

University

Year of Passing

Any other non-engineering Post Graduation professional qualifications : ....................................................................................................................................................... ....................................................................................................................................................... Field of specialisation in engineering, if any :... Enclose attested photocopies of each of the above certificates

3.Name & Category of membership of engineering related professional institution(s). (a).................................................................................................................................... (b)................................................................................................................................... (c).................................................................................................................................... (d)....................................................................................................................................

Each sponsor has to sign one item after due verification.

4.Record of engineering experience since graduation in chronological order. (Ref. item 4.1 of Guidelines) Dates Employer/Client Job Title Major job responsibilities (if self employed/consultant)

Attach additional sheets if more space is required. 5. Professional Development Programme(s)/Activities for last five years, starting from current year. 5.1 Recognised Training Programme(s), Conferences, Seminars, Workshops, Technical Presentations attended /participated. Sl. No. 1. 2. 3. 4. Title/Subject Duration & Dates Nature of Participation Conducting Organisation

Attach additional sheets if required.

5.2 Books/Articles/Research/Technical Reports written by applicant Title Date of Finalisation

Each sponsor is expected to sign at least one item after due verification.

Published by/Submitted to

5.3 Professional contributions in emergency works (e.g. Flood Relief, Earthquake, Fire Fighting etc.) Enclose supporting documents for Sl No. 5. 6. Discipline of Professional Engineer applied for: Civil Chemical Mechanical 7. Assessment Examination, if applicable (Ref. Item 6 of Guidelines) 7.1 Choice of Examination Centre Code 7.2 Discipline Specialisation (wherever available) (Please see Assessment Examination in www.ieindia.org for the available specialisations in Module 2 (Part II) and choice of Examination Centre) 7.3 Examination fee Rs.4000/- to be given by Demand Draft (An additional fee of Rs.3000/- towards interview by video conferencing will be required to pay by the applicant after successful completion of PE online assessment examination) 8. For Renewal of PE Certification Rs. 3000/- to be paid towards the fee for renewal of PE Certification with an additional amount of Rs.3000/- towards the fee for appearing in the interview through video conferencing. [N.B.:- For transfer from PE(India) to IntPE (India) a separate form is to be filled up, which is available in the website and required transfer fee is Rs.10,000/- .] Yes No Yes No Electrical Mining

9. Self-appraisal for certification as Professional Engineer (Refer item 4/6.5(a) of Guidelines as applicable) (Attach separate sheet) 10. Declaration: _ _ _ _ _ _ Date : Applicants Signature ........................................ Applicants Name .............................................. Nos. Enclosures : 1. Qualification Certificate 2. Professional Development Programmes Certificate (s) 3. Bank Draft/Credit Card Authorisation 4. Others I wish to be certified as Professional Engineer in discipline as mentioned in the application form. I agree to abide by the Code of Ethics established for Professional Engineers and to be held individually accountable for my actions. I have no objection against my certification process being stopped, should there be any inaccuracy in the submitted information. I have no objection against my certificate being terminated after certification according to prevailing rules on the date of termination as Professional Engineer. I agree that the decision on Certification and Termination shall be binding on me. I hereby swear that the contents of the items described in this application documents are true and correct.

Rs,

No.

Sponsors : From personal knowledge of the applicant and in consideration of his/her qualifications as stated
in the form, we recommend him/her as being in every way a fit and proper person to be certified as Professional Engineer. (Ref. Item 5 of Guidelines)

Name 1. 2 3.

Membership No., Grade & Name of recognised professional Institution

Signature

PART II (To be filled by National Committee) 1. Passed Professional Engineer Assessment Examination (a) Examination Discipline.Roll No............................ Date of Passing (b) Experience including Continuous Professional Development Date of Interview .................................................... Assessment (in brief) .............................................. .... .. .. .. 2. Conducted by member association 3. Recommendations for Certification as Professional Engineer Yes If yes, state discipline recommended Discipline ................................. Reference No............................ Date.......................................... ________ Signature ___________________________ Authorised Signatorys designation _______________________________ Name of professional engineering association No

PART III (For IEIs use only)

Verification Certification Approved / Not approved Discipline .................................................... Registration No............................................. Date of intimation of Certification to the applicant Date of despatch of Professional Engineer Certificate

________ Signature _________________________ Authorised Signatorys Designation for Board for Certification of Professional Engineer

(CONFIDENTIAL when completed) (Not applicable for renewal of certification) To be filled by each Sponsor and sent separately to BFC in a sealed envelop (Ref. Item 5 of Guidelines) Report on Shri/Smt 1. 2. How long have known the applicant? In what capacity? . Years Employer Colleague 3. Sr. Colleague Friend Mentor Client

Do you recommended the applicant for certification as Professional Engineer Yes No

4. If yes please give your own impression of the candidate and why you consider him/her a fit person to be certified as professional engineer, identifying his/her engineering qualities & achievement (around 50 words) Signature: .. Name of the Sponsor: . Correspondence Address E-mail id :

Fellow No./P Eng No.. Name of the professional institution/society . To Board for Certification of Professional Engineer The Institution of Engineers (India) 8 Gokhale Road Kolkata 700 020