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7/13/2014 Membership Application Form

http://www.iiche.org.in/membership_application_form.html

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INDIAN INSTITUTE OF CHEMICAL ENGINEER

Dr.H.L.Roy Buliding, Jaduvpur university Campus.

Raja Subhod Chandra Mullick Road

Kolkata-700032

Email-id:- [email protected]

Telephone :-033-24129314/2412931

Membership Application Form

Catagory of Membership applied forMember:

Life Member:-

Associate Member:-

Life Associate Member:-

Transfer of Membership catagory:- SM---->AM AM---->M

1. NAME (IN BLOCK LETTERS)

Last,First,Middle

[Last]

[First]

[Middle]

2. Designation :-

3. Address [official] 4. Address [Residential]

Pincode :-

Pincode :-

Phone-Office:-

Phone-Residence:-

Mobile :-

Email-Office:- Email-residence:-

5. Address for Communication:-Office:-

Residence:-

6. Date of Birth :-

(dd/mm/yyyy) / /

7. Sex:- Male Female 8. Nationality:-

9. EDUCATIONAL QUALIFICATIONS :-

(Copy of degree(s)/ diploma(s) must be attached if you are not already a Member of IIChE or if you have obtained additional

qualifications after becomeing a corporate member.)

Degree/Diploma Year College/University Major Field Code

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Degree Code: Chem. Engg: 01, Chem. Tech: 02, Allied Process Tech.: 03, Other Engg: 04, Science: 05 Diploma Code: AMIIChE

06, AMIE: 07, Dip. Chem. Engg. / Tech.: 08, Others (Specify):09.

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10. PROFESSIONAL EXPERIENCE: (Attach separate sheets if necessary)

Employee (Current) Employee (Previous)

Address:- Address:-

Position :-

From: To:

Position :-

From: To:

Nature of duties and responsibilities related to Chemical Engineering:

11. SPECIALISATION:-

12. In case you were a student member / associate member, Membership Number: SM/AM

Year: From: To:

13. SUPPORTERS (One must be a corporate member of IIChE, the other may be employer.

Name:- Name:-

Address:- Address:-

Membership Number:- Membership Number:-

Signature: Signature:

Seal: Seal:

14. PAYMENT DETAIALS:-

Payment should be made by at per Multicity Cheque / Demand Draft(DD) in favour of

INDIAN INSTITUTE OF CHEMICAL ENGINEERS payable at Kolkata

Registration Fee Rs:- Admission/Transfer Fee Rs:-

Annual Subscription/Compouding Fee Total Payment enclose

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Rs:- Rs:-

Demand Draft/Cheque on (Bank) :No: Dated :

15.DECLARATION BY THE APPLICANT:

I, the undersigned, attest that the particulars given above by me are true. If elected to Membership, I agree to abide by the

Constitution and the bye-laws of the Indian Institute of Chemical Engineers.

Place:-

Date:-

Signature of the Applicant

FOR OFFICE USE ONLY

Application Receive No:-

- -

Acknowledged on:-

- -

Registration No:-

To Register/Secretry:

- -

From Register/Secretry:

- -

To Council:

- -

AdviceSent No:

- -

Formalities Completed No:- - -

Council's Decision

Elected / Not elected

Membership Number Allotted:

Receipt Number:

Despatched on:

- -

Despatched on: - -

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Fees & Subscription Details

Registration Fees for all the categories Rs:- 100/-

Members Catagories Admission Fee(RS) Annual Subscription Fee(RS)

Member 350 350

Associate Member

(-age 35 years and above)350 350

Associate Member

(-age below 35 years)250 250

LIFE MEMBERS

Age (in years) as on 31st March Next Compounding Fees(RS)

26-50 4,000/-

51-60 3,000/-

61 and above 2,000/-

LIFE ASSOCIATE MEMBERS

Age (in years) as on 31st March Next Compounding Fees(RS)

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All age groups 3,000/-

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