--- Registration will only be processed if all requested information is provided and accompanied by full payment. ---

LAST NAME FIRST NAME EXT MIDDLE NAME NAME TO APPEAR ON ID

R E G I S T R A T I O N F O R M

Name

IECEP ID Number IECEP Chapter Affiliation

PRC License Number

PECE ECE ECT

PRC Expiration Date

E-mail Address Mobile Number

Company

Type of Industry

Academe Consultancy Management Power Sector

Broadcasting Electronics Manufacturing Semiconductor

Computer Government Military Telecommunication

Construction Information Technology Others: _______________________________________

__________________________________________

Signature

--- Please accomplish the form and submit via email to: iecepmidyear2016@gmail.com ---

FOR IECEP MIDYEAR CONVENTION SECRETARIAT USE ONLY

Conference Registration Number

Payment Mode Cash Check Bank

Payment Type Pre-registered On-site Non-paying

Payment Date Amount Paid

Check Number (for company check payments)

IECEP O.R. Number Issued Date Issued

Payment can be deposited to:Account Name: Institute of Electronics Engineers of the Philippines, Inc-SOCCSKSARGENAccount Number: 009343-0373-22 Bank Name: BPI-GenSan Santiago Branch