Application for Membership ASSOCIATE

FORM N.S.E. 1PhotographNO.NATIONAL ENGINEERING CENTREE-mail: info@nse.org.ngOff National Mosque-Labour House road,Central Business area,Abuja, Nigeria.Website: http://www.nse.org.ngApplication for MembershipASSOCIATEE-MAIL ADDRESS………………………………………………TELEPHONE NO.................................1. NAME: ………………………………………………………………………………………………………(CAPITALS) SURNAME(OTHER NAMES)2. HOME ADDRESS:………………………………………………………………………………………….………………………………………………………………………………………………………………….3. POSTAL ADDRESS:………………………………………………………………………………………...4. DATE OF BIRTH: 5. SEX: M FD D M M Y Y Y Y6. NATIONALITY:…………………………………………………………………………………………….7. FIELD OF ENGINEERING:……………………………………………………………………………….8. SPECIALISATION:………………………………………………………………………………………..9. PRESENT PLACE OF EMPLOYMENT:…………………………………………………….……………10. POSITION: ………………………………………………………………………..DATA OF NEXT OF KIN11. NAME OF NEXT OF KIN:………………………………………………………………………………12. ADDRESS:..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………13. E-MAIL:…………………………………… 14. MOBILE NO..:…………………………………NSE Associate Application Form 1/6

ACADEMIC DATA15. DETAILS OF SECONDARY EDUCATION (INCLUDE DATES)16. DETAILS OF UNIVERSITY/TERTIARY INSTITUTIONS ATTENDED (INCLUDE DATES)S/NUNIVERSITY/TERTIARY INSTITUTIONSQUALIFICATIONSOBTAINEDDATES(Attach certified photocopies of certificates)17. MEMBERSHIP OF OTHER PROFESSIONAL INSTITUTIONS/SOCIETIESS/N NAMES OF INSTITUTIONS DATES(Attach certified photocopies of certificates)18. OTHER DISTINCTIONS/AWARDSS/N DISTINCTIONS/AWARDS DATES(Attach certified photocopies of certificates)19. PROPOSERSWe recommend the application of …………………………….………………………………… in his desireto become a …………………. of the Society and hereby propose him to the Council.S/N NAME IN FULL GRADE SIGNATURE1.MEMBERSHIPREG. NO.DATE2.(* Must be Financial Corporate Member of the Society).NSE Associate Application Form 2/6

MEMBERSHIP OF BRANCHES AND DIVISIONSA. BRANCHThis section must be completed by the chairman of the candidate’s intended Branch. The application will not be processed furtherwithout theseSee lists of Branches on page 4.1. BRANCH…..………………………………………………………………………………………….2. NAME OF BRANCH CHAIRMAN:…………………………………………………………………...3. HOW LONG HAVE YOU KNOWN THE CANDIDATE?4. IS THE CANDIDATE ACTIVE AT THE BRANCH?YESNO5. BRANCH CHAIRMAN’S SIGNATURE……………………………………………………………..B. DIVISION (S)To be completed by the chairman of one of the intended divisions. See the list of Divisions on page 41. DIVISION:…………………………………………………………………………………………….2. NAME OF DIVISION CHAIRMAN:………………………………………………………………...3. HOW LONG HAVE YOU KNOWN THE CANDIDATE?4. IS THE CANDIDATE ACTIVE AT THE DIVISION?YESNO5. DIVISION CHAIRMAN’S SIGNATURE……………………………………………………………..NSE Associate Application Form 3/6

The Branches Are:1. ABA 21. ENUGU 41. MAKURDI2. ABEOKUTA 22. EGBIN 42. MINNA3. ABAKALIKI 23. GOMBE 43. NEW BUSSA4. ABUJA 24. GUSAU 44. NSUKKA5. ADO-EKITI 25. IBADAN 45. OMOKU6. AJAOKUTA 26. IKEJA 46. ONITSHA7. AKURE 27. IKOT-ABASI 47. OSHOGBO8. APAPA 28. ILE-IFE 48. OWERRI9. ASABA 29. ILESHA 49. PORT-HARCOURT10. AWKA 30. ILORIN 50. SOKOTO11. BAUCHI 31. JALINGO 51. UMUAHIA12. BENIN 32. JOS 52. UYO13. BIDA 33. KADUNA 53. VICTORIA ISLAND14. BIRNIN-KEBBI 34. KANO 54. WARRI15. BONNY 35. KATSINA 55. YENAGOA16. CALABAR 36. LAFIA 56. YOLA17. DAMATURU 37. LAGOS 57. ZARIA18. DUTSE 38. LOKOJA19. EKPOMA 39. MAIDUGURI20. EKET 40. MAITAMAThe Divisions are:1. Aeronautical 7. Civil 13. Mechanical2. Agricultural 8. Electrical 14. Metallurgical, Materials3. Appraisers and Cost Engineers 9. Environmental & Mining4. APWEN 10. Geotechnical 15. Petroleum5. Automotive 11. Industrial 16. Space6. Chemical 12. Marine Engineering & Naval 17. StructuralArchitecture 18. WaterA member is free to belong to up to 3 Divisions……………………………………………………………………………………………………………..FOR OFFICIAL USE ONLY(Admission or Transfer)Date of Application………………………………………………………………………………………………….…..Recommendation of Membership Board………………………………………………………………………………..Admission approved by the Council this …………………………….. day of ………………………………………...Name/Signature of Coordinator………………………………………………………………………………................Name/Signature of Head, Membership Services………………………………………………………………………..Name/Signature of Chairman, Membership Board………………………………………………………………….….Number in registerNSE Associate Application Form 4/6

DATE(FROM - TO)STATEMENT OF EXPERIENCE AND RESPONSIBILITYPOSITION, EMPLOYER AND DESCRIPTION OF PROJECT(WITH COST) E.T.C.CONFIRMEDBYNSE Associate Application Form 5/6

DECLARATION:I, ……………………………………………………………………………….. agree with theaims and objects of the Society and will abide by its Memorandum and Articles.I also promise that, in the event of my admission, I will be governed by the Memorandumand Articles of Association of the Society for the time being in force, and its code of ethicsand that I will accept as final and binding the decisions of the executive Council on Allmatters dealt with by them in accordance with the provision of the said memorandum andarticles.I will advance the objects of the Society by presenting papers and discussion and attendingthe meetings of the Society as often as possible.Date ……………………… Signature of Candidate ……………………………..*NB:Please attach a photocopy of the receipt for the Purchase of this form. Failure to do this may delay yourapplication.NSE Associate Application Form 6/6