Asean Engineer Application Form 4i631u
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APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten)
APPLICANT’S CHECKLIST √ COVERING LETTER √ ACCOMPLISHED APPLICATION FORM √ CURRICULUM VITAE CAREER EPISODE REPORT (APEC ENGINEER ONLY) √ ING DOCUMENTS SU A√ PRC CERTIFICATE OF REGISTRATION √ VALID PROFESSIONAL IDENTIFICATION CARD √ CERTIFICATE OF GOOD STANDING FROM ACCREDITED PROFESSIONAL ORGANIZATION (APO) √
ENDORSEMENT LETTER FROM APO (NATIONAL) √ S RECENT PORT SIZE PHOTOGRAPHS (2” X 2”), WHITE BACKGROUND WITH NAME WRITTEN AT THE BACK √ APPLICANT’S DECLARATION A√ 3 SETS OF DOCUMENTS √ √
APPLICATION FEE PAYMENT (TO PTC) ENDORSEMENT OF DOCUMENTS TO PTC
HIP FEE PAYMENT (AFTER REVIEW/ INTERVIEW, IF ED) NOTE:
1) Triplicate copies of the accomplished application forms, including copies of all ing documents must be submitted; A4 size of paper not less than substance (80 gms) thickness shall be used throughout; photocopies of large documents shall be reduced accordingly. Each set shall be submitted using a CLEAR BOOK FOLDER. 2) All applications must be originally-signed by the applicant and shall be delivered or mailed to: Philippine Technological Council, Inc. c/o Minercon Intl. 405 – 406 National Engineering Center Bldg. Juinio Hall, Osmeña ave. cor. F. Agoncillo st. University of the Philippines, Diliman, Quezon City. Tel/Fax no: 926 – 6893 E-MAILED APPLICATIONS OR COMPUTER-GENERATED SIGNATURES ON THE APPLICATION FORMS WILL NOT BE Please paste/computer print ACCEPTED. recent (6mos) port size (50mm x 50mm) picture with white background. ATTIRE
1
MALE – COAT & TIE FEMALE - CORPORATE
APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten)
APEC ENGINEER √ ASEAN ENGINEER 1.
PERSONAL DETAILS
Title: Prof Dr Eng Mr Mrs Ms Surname: Given Names (in full): Middle Name: Date of Birth: Name of Employer: Private Address ( preferred mailing address): Business Address ( Postal Code: Ph:( ) E-mail: Mobile: ( )
Country: Fax:(
)
preferred mailing address):
Postal Code: N/A Ph:( ) Fax:(
Country: )
2. EDUCATIONAL/PROFESSIONAL QUALIFICATIONS Academic Degree: University or College: Professional Discipline: PRC Registration No: Fields of Specialization:
Date of Graduation: Date of PRC registration:
General Career Objective:
3. HIP Please tick the accredited professional organization where you are a member. Society of Aerospace Engineers of the Philippines (SAEP) Philippine Society of Agricultural Engineers (PSAE) √ Philippine Institute of Civil Engineers (PICE) Philippine Institute of Chemical Engineers (PIChE) Institute of Integrated Electrical Engineers (IIEE) Institute of Electronics Engineers of the Philippines (IECEP) Geodetic Engineers of the Philippines (GEP) Philippine Society of Mechanical Engineers (PSME) Society of Metallurgical Engineers of the Philippines (SMEP) Philippine Society of Mining Engineers (PSEM) Society of Naval Architects and Marine Engineers (SONAME) Philippine Society of Sanitary Engineers (PSSE) Philippine Institute of Industrial Engineers (PIIE) 4. SEVEN (7) YEARS PROFESSIONAL EXPERIENCE (PLEASE PROVIDE ING DOCUMENTS)
2
APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten)
Inclusive Dates
Company
Position
Main Responsibility
(USE ADDITIONAL SHEET IF NECESSARY)
5. TWO (2) YEARS SIGNIFICANT ENGINEERING (PLEASE PROVIDE ING DOCUMENTS)
Inclusive Dates
Company
Position
Main Responsibility
(USE ADDITIONAL SHEET IF NECESSARY)
NOTE: ENGINEERING PRACTICE REPORT (FOR APEC ENGINEER ONLY) IS ON SEPARATE FORM.
6. CONTINUING PROFESSIONAL DEVELOPMENT (PLEASE PROVIDE ING DOCUMENTS)
REF
DATE
TYPE
D activity/topic/provider
Actual
Time (hours) Weight factor
Weighted hours
Total D activities (Goal 150 hours/3 year period) ____________________________________________________________________________________________________ _ (USE ADDITIONAL SHEET IF NECESSARY)
7. APPLICANT’S DECLARATION
3
APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten) I certify under penalty of perjury and/or falsification of public documents that all the documents submitted in of this application are true copies of the authentic original documents and that I am prepared to submit these original documents if and when required. I hereby declare that all statements of facts in my Application form and Engineering Practice Report are true and correct and I have made claims of acquired competencies in good faith. The report is my own work. I confirm that I have read and that I understand the PTC Code of Ethics and the Codes of Ethics of my profession. I agree that, if itted as an Advanced Level Engineer, I will observe and will be bound by these Codes of Ethics. I understand that I have an obligation to inform PTC and my APO of any matter that may affect my fitness for ission to and continued inclusion in the Advanced Level Engineer . In of my application for registration on the Advanced Level Engineer , I
certify that I have been engaged in independent practice or have worked as an employee under the general direction of a professional or have been enrolled in a formal post-graduate training program in my area of expertise for at least the equivalent of one full-time year during the past three years;
certify that over that period I have maintained my continuing professional development (D) by involvement in activities related to my particular area of expertise;
acknowledge that, on renewal of my APO hip, by paying my registration fee for the coming year, I will be indicating to the council my clear intention to abide by the undertakings I have made in applying for registration, and will be confirming that my circumstances have not placed me outside the minimum practice requirements;
acknowledge that my compliance with these D requirements during the period in which I remain ed may be audited at any time; and
consent to my business details being published in any form associated with my registration as Advanced Level Engineer. Signature: …………………………………………………………………. (Signature of declarant) Declared at
Date:
this (place)
(date)
Before me (notarized)
…………………………………………………………………………………………………………………………………………. Residing at ……………………………………………………………………………………………………………………………………........ (Name, profession and address in BLOCK LETTERS, of person authorized to certify the declaration. Please sign above name.)
4
APPLICANT’S CHECKLIST √ COVERING LETTER √ ACCOMPLISHED APPLICATION FORM √ CURRICULUM VITAE CAREER EPISODE REPORT (APEC ENGINEER ONLY) √ ING DOCUMENTS SU A√ PRC CERTIFICATE OF REGISTRATION √ VALID PROFESSIONAL IDENTIFICATION CARD √ CERTIFICATE OF GOOD STANDING FROM ACCREDITED PROFESSIONAL ORGANIZATION (APO) √
ENDORSEMENT LETTER FROM APO (NATIONAL) √ S RECENT PORT SIZE PHOTOGRAPHS (2” X 2”), WHITE BACKGROUND WITH NAME WRITTEN AT THE BACK √ APPLICANT’S DECLARATION A√ 3 SETS OF DOCUMENTS √ √
APPLICATION FEE PAYMENT (TO PTC) ENDORSEMENT OF DOCUMENTS TO PTC
HIP FEE PAYMENT (AFTER REVIEW/ INTERVIEW, IF ED) NOTE:
1) Triplicate copies of the accomplished application forms, including copies of all ing documents must be submitted; A4 size of paper not less than substance (80 gms) thickness shall be used throughout; photocopies of large documents shall be reduced accordingly. Each set shall be submitted using a CLEAR BOOK FOLDER. 2) All applications must be originally-signed by the applicant and shall be delivered or mailed to: Philippine Technological Council, Inc. c/o Minercon Intl. 405 – 406 National Engineering Center Bldg. Juinio Hall, Osmeña ave. cor. F. Agoncillo st. University of the Philippines, Diliman, Quezon City. Tel/Fax no: 926 – 6893 E-MAILED APPLICATIONS OR COMPUTER-GENERATED SIGNATURES ON THE APPLICATION FORMS WILL NOT BE Please paste/computer print ACCEPTED. recent (6mos) port size (50mm x 50mm) picture with white background. ATTIRE
1
MALE – COAT & TIE FEMALE - CORPORATE
APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten)
APEC ENGINEER √ ASEAN ENGINEER 1.
PERSONAL DETAILS
Title: Prof Dr Eng Mr Mrs Ms Surname: Given Names (in full): Middle Name: Date of Birth: Name of Employer: Private Address ( preferred mailing address): Business Address ( Postal Code: Ph:( ) E-mail: Mobile: ( )
Country: Fax:(
)
preferred mailing address):
Postal Code: N/A Ph:( ) Fax:(
Country: )
2. EDUCATIONAL/PROFESSIONAL QUALIFICATIONS Academic Degree: University or College: Professional Discipline: PRC Registration No: Fields of Specialization:
Date of Graduation: Date of PRC registration:
General Career Objective:
3. HIP Please tick the accredited professional organization where you are a member. Society of Aerospace Engineers of the Philippines (SAEP) Philippine Society of Agricultural Engineers (PSAE) √ Philippine Institute of Civil Engineers (PICE) Philippine Institute of Chemical Engineers (PIChE) Institute of Integrated Electrical Engineers (IIEE) Institute of Electronics Engineers of the Philippines (IECEP) Geodetic Engineers of the Philippines (GEP) Philippine Society of Mechanical Engineers (PSME) Society of Metallurgical Engineers of the Philippines (SMEP) Philippine Society of Mining Engineers (PSEM) Society of Naval Architects and Marine Engineers (SONAME) Philippine Society of Sanitary Engineers (PSSE) Philippine Institute of Industrial Engineers (PIIE) 4. SEVEN (7) YEARS PROFESSIONAL EXPERIENCE (PLEASE PROVIDE ING DOCUMENTS)
2
APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten)
Inclusive Dates
Company
Position
Main Responsibility
(USE ADDITIONAL SHEET IF NECESSARY)
5. TWO (2) YEARS SIGNIFICANT ENGINEERING (PLEASE PROVIDE ING DOCUMENTS)
Inclusive Dates
Company
Position
Main Responsibility
(USE ADDITIONAL SHEET IF NECESSARY)
NOTE: ENGINEERING PRACTICE REPORT (FOR APEC ENGINEER ONLY) IS ON SEPARATE FORM.
6. CONTINUING PROFESSIONAL DEVELOPMENT (PLEASE PROVIDE ING DOCUMENTS)
REF
DATE
TYPE
D activity/topic/provider
Actual
Time (hours) Weight factor
Weighted hours
Total D activities (Goal 150 hours/3 year period) ____________________________________________________________________________________________________ _ (USE ADDITIONAL SHEET IF NECESSARY)
7. APPLICANT’S DECLARATION
3
APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten) I certify under penalty of perjury and/or falsification of public documents that all the documents submitted in of this application are true copies of the authentic original documents and that I am prepared to submit these original documents if and when required. I hereby declare that all statements of facts in my Application form and Engineering Practice Report are true and correct and I have made claims of acquired competencies in good faith. The report is my own work. I confirm that I have read and that I understand the PTC Code of Ethics and the Codes of Ethics of my profession. I agree that, if itted as an Advanced Level Engineer, I will observe and will be bound by these Codes of Ethics. I understand that I have an obligation to inform PTC and my APO of any matter that may affect my fitness for ission to and continued inclusion in the Advanced Level Engineer . In of my application for registration on the Advanced Level Engineer , I
certify that I have been engaged in independent practice or have worked as an employee under the general direction of a professional or have been enrolled in a formal post-graduate training program in my area of expertise for at least the equivalent of one full-time year during the past three years;
certify that over that period I have maintained my continuing professional development (D) by involvement in activities related to my particular area of expertise;
acknowledge that, on renewal of my APO hip, by paying my registration fee for the coming year, I will be indicating to the council my clear intention to abide by the undertakings I have made in applying for registration, and will be confirming that my circumstances have not placed me outside the minimum practice requirements;
acknowledge that my compliance with these D requirements during the period in which I remain ed may be audited at any time; and
consent to my business details being published in any form associated with my registration as Advanced Level Engineer. Signature: …………………………………………………………………. (Signature of declarant) Declared at
Date:
this (place)
(date)
Before me (notarized)
…………………………………………………………………………………………………………………………………………. Residing at ……………………………………………………………………………………………………………………………………........ (Name, profession and address in BLOCK LETTERS, of person authorized to certify the declaration. Please sign above name.)
4
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