FORMULIR APLIKASIASEAN CHARTERED PROFESSIONAL ENGINEER

INDONESIA MONITORING COMMITTEE2013

Dapat diunduh dari situs IMC, http://imc.or.id/

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APPLICATION FOR A PROFESSIONAL ENGINEER TO BE REGISTERED AS ASEAN CHARTERED PROFESSIONAL ENGINEER

(ACPE)(To be completed by Applicant in BLOCK LETTERS with BLUE INK)

Name:

Name to be put in the certificate:

Address:

Tel . No.: Fax. No.:

E-mail:

Identity Card No.: Date of Birth:

First Degree / University:

Discipline of Engineering:

Graduate Engineer Registration No.:

Date of Registration:

Professional Engineer Registration No.:

Date of Registration:

Branch of Engineering:

Discipline for ACPE Registration (select 1 discipline only): Mechanical Electrical Chemical Physic

Aeronautical Marine Tech Industrial Environmental

Petroleum Mining Geodetic

Civil

Structural Geotechnical Water Resources Transportation

I enclose herewith * money order / bank draft / cheque no. :

for the amount of Rp. being the fee.

Date of previous application:(Write NIL if not applicable)

Date:( )

*delete whichever is not applicable (signature)

Silakan kirimkan salinan aplikasi ACPE melalui e-mail ke secretariat@imc.or.id

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PORTOFOLIO FOR THE APPLICATION AS ASEAN CHARTERED PROFESSIONAL ENGINEERName:

PROFESSIONAL EXPERIENCE IN RESPONSIBLE CHARGE OF SIGNIFICANT ENGINEERING WORK

A B C EXPERIENCE AREA (in months) EDate (month

& year) relating to

each appointment

Example: April 87 to January

97

State concisely title of position held, name of employer, location and description of each work (make statement brief and concise, designating each work upon which

engaged with or change of position separately: include some indication of magnitude and complexity of work in which engaged, your duties and degree of responsibility)

(if necessary additional sheets may be attached)

Name, position and address of

professional engineer

under whom served &

contact no.

Tot

al

D1 D2 D3 D4 D5Signature of any

professional engineers who has personal

knowledge of applicants training or experience in

the period mentioned

Des

ign

/ off

ice

Sit

e / f

ield

Pla

nnin

g /

man

agem

ent

Oth

er

engi

neer

ing

wor

ks

Mas

ters

/ po

st

grad

uate

s /

stud

y / r

esea

rch

/ te

achi

ng

Total Months

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DECLARATION FOR THE APPLICATION AS ASEAN CHARTERED PROFESSIONAL ENGINEER

I hereby declare that:

I have had years of practical experience in engineering.

YES NO

I am a Professional Engineer

I meet the entire requirement as stated in Article 3 of the

ASEAN Mutual Recognition Arrangement (MRA)

No disciplinary action have been taken against me

I am not a bankrupt

Others:

Yours Sincerely,

(signature)

Name:

PE Reg. No.:

Date: Note: Please tick (√) in the relevant box.

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