Form IEM(S)-Aug06-New.pmd - The Institution of Engineers Malaysia

INSTITUSI JURUTERA MALAYSIA
THE INSTITUTION OF ENGINEERS, MALAYSIA
PERMOHONAN UNTUK KEMASUKAN SEBAGAI AHLI SISWA
APPLICATION FOR ADMISSION AS STUDENT MEMBER
BORANG/FORM IEM (S)
1. BUTIR-BUTIR DIRI
PERSONAL PARTICULARS
Nama Penuh: ....................................................................................................................................................
Full Name:
Alamat Tetap: ..................................................................................................................................................
Permanent Address:
..................................................................................................................................................
GAMBAR
Photograph
Alamat Surat-Menyurat: ....................................................................................................................................
Postal Address:
....................................................................................................................................
Kewarganegaraan: ............................................................... Tempat Lahir: ...................................................
Nationality
Place of Birth:
Nombor Kad Pengenalan: ................................................... Tarikh Lahir: .....................................................
Identity Card Number:
Date of Birth:
Nombor Telefon Rumah: .................................................... Nombor Telefon Bimbit: ................................................................................
House Telephone Number:
Handphone Number:
Alamat E-mel: .................................................................... Permohonan Sebelum Ini (jika ada): ...............................................................
Email Address:
Year of Earlier Application (if any):
2. BUTIR-BUTIR PERMOHONAN
APPLICATION PARTICULARS
Institusi Pengajian Tinggi: ................................................ Disiplin Kejuruteraan: ................................................................................
Institution of Higher Learning:
Discipline of Engineering:
Tajuk Program Kejuruteraan : ........................................... Ijazah Dikurniakan: ....................................................................................
Title of Engineering Programme:
Title of Degree
Tarikh Mula Kursus : ........................................................ Tahun Tamatkan Kursus: ............................................................................
Date of Course Commencement:
Expected Year of Graduation:
Tahun Kursus yang sedang diikuti: ..................................... Kelayakan Kemasukan: ..............................................................................
Current Academic Year:
(STPM, Matrikulasi, Diploma or Sijil)
Entry Qualification:
(STPM, Matriculation, Diploma or Certificate)
Pendidikan Sekolah Menengah/Kolej Kejuruteraan Kelulusan / Anugerah Tahun SijilDikeluarkan
Secondary Education/College Examinations passed/awarded Year .of Awards
........................................................................................ ................................................................ .............................................
........................................................................................ ................................................................ .............................................
3. KENYATAAN OLEH DEKAN* (Untuk Pemohon dari IPTA atau IPTS)
STATEMENT BY THE DEAN *(For Applicant from Local Institutions of Higher Learning)
Mengikut Akta Universiti dan Universiti Kolej 1975 (Pindaan) Pelajar-Pelajar Institusi Pengajian Tinggi adalah dilarang menjadi Ahli
kepada mana Pertubuhan atau Persatuan melainkan dengan mendapat persetujuan bertulis daripada Naib Canselor atau Rektor. Bagi pihak
Institusi Pengajian Tinggi, kami tiada halangan dalam membenarkan pemohon untuk menjadi Ahli Siswa Institusi Jurutera Malaysia.
In accordance to the Universities and University/Colleges Act (Amendment) 1975, students of Institutions of Higher Learning are prohibited to be members of any
Society, unless prior approval in writing have been obtained from the Vice Chancellor or Rector. On behalf of the Institution of Higher Learning, we have no objection
in permitting the Applicant to be admitted as a Student member of The Institution of Engineers,M alaysia.
Tandatangan: ...................................................................
Signature:
Nama Dekan: ................................................................... Jawatan dan Cop Rasmi: ..........................................................................
Name of Dean:
Designation and official stamp:
Tarikh: ............................................................................ Nombor Ahli IEM (jika ada) ....................................................................
Date:
IEM Membership Number (if any):
*(Ruang ini mestilah ditandatangani oleh Dekan atau Ketua Jabatan Kejuruteraan dari Institusi Pengajian Tinggi)
*(This section must be signed either by the Dean or Head of Engineering Department from the Institution of Higher Learning)
Implemention Date: 12 Sept. 2006