‫الهيئة السعودية للمهندسين‬

‫) سم‬5×5( ‫الصورة الشخصية‬

Personal Photo (5X5 cm)
‫مركز االعتماد المهني الهندسي‬
‫الرجاء كتابة االسم خلف الصورة‬ Saudi Council of Engineers, SCE
Please write the name Professional Accreditation Center
on back of Picture

‫نموذج طلب الحصول على درجة مهنية‬

Professional Engineering Degree Application

Degree Renewal ‫الدرجة‬ ‫تجديد‬ New Degree Request ‫ طلب درجة مهنية‬

:Personal Data -1 :‫الشخصية‬ ‫ المعلومات‬- 1

:.Registration (SCE membership) no                   :)‫رقم التسجيل (عضوية الهيئة‬

female ‫ أنثى‬male  ‫ ذكر‬                         :‫االسم الرباعي‬

:Name in English                   :‫االسم باإلنجليزية‬

:.National ID / Igama no                               :‫ اإلقامة‬/ ‫رقم السجل المدني‬

Non Saudi (specify) )‫ غير سعودي (حدد‬

:Nationality Saudi ‫سعودي‬ :‫الجنسية‬
.................................................

     
:‫التاريخ ومكان اإلصدار‬ :‫رقم جواز السفر‬
Passport no.: Date & Issuing Authority:   
    
  

:Place of birth       :‫مكان الميالد‬ :Date of birth               :‫تاريخ الميالد‬

:Position       :‫ مسمى الوظيفة‬:Employer       :‫جهة العمل‬

:City       :‫ المدينة‬:.P.O.Box no                   :‫ب‬.‫ص‬

:Country       :‫ الدولة‬:Postal Code                :‫الرمز البريدي‬

:Extension                :‫تحويله‬ :.Tel                            :‫هاتف‬

:Extension                :‫تحويله‬ :.Fax                            :‫فاكس‬

:Mobile                                         :‫جوال‬

:E-mail       :‫البريد االلكتروني‬

:Professional Degree Applying for& Fees (3 years) -2 :)‫ سنوات‬3( ‫ الدرجة المهنية والرسوم المطلوبة‬- 2
Consultant, CE ‫ مهندس مستشار‬ Professional, PE ‫ مهندس محترف‬ Associate, AE ‫ مهندس مشارك‬ Engineer, E ‫ مهندس‬
SR 2800 ‫ لاير‬2800 SR 2300 ‫ لاير‬2300 SR 1700 ‫ لاير‬1700 SR 1250 ‫ لاير‬1250
 :Academic Qualifications in engineering disciplines -3 :‫ – المؤهالت العلمية في مجاالت الهندسة‬3
‫بلد التخرج‬ ‫ المعهد‬/ ‫الجامعة‬ ‫التخصص الرئيسي‬ ‫سنة التخرج‬ ‫المؤهل العلمي الجامعي‬
Place of graduation University/institution Main major Year of graduation University degrees
                        .B S ‫ بكالوريوس‬
                        .M. S ‫ماجستير‬ 
                        .Ph D ‫دكتوراه‬ 
                       

     :Specialization :‫التخصص الدقيق‬

:Work Experiences -4 :‫ – الخبرات العملية‬4

:Employment & Job Ranks -4/1 :‫ المراتب والدرجات الوظيفية‬-4/1

‫المدة‬ ‫تاريخ البدء‬ ‫مسمى الوظيفة‬ ‫المكان‬ ‫المرتبة أو الدرجة‬ ‫جهة العمل‬
Duration Commencing date Job title Place Rank Name of employer
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   

:Leading Positions during Professional Work -4/2 :‫ المناصب القيادية التي تقلدتها أثناء عملك المهني‬-2/4

)‫المدة (البداية والنهاية‬ ‫المنصب‬ ‫جهة العمل‬

Duration (start & end) Position Name of employer
                       
                       
                       
                       
                       
                       
                       
                       

Specialized Professional Grades -5 ‫ الدرجات المهنية التخصصية‬-5

:)… ,PE, SAVE, PMI( :).‫ الخ‬.... ،‫ الهندسة القيمية‬،‫ إدارة المشاريع‬،‫(مهندس محترف‬

‫تاريخ الصالحية‬ ‫الجهة المانحة‬ ‫رقم التسجيل‬ ‫المجـال‬ ‫الدرجة المهنية‬

Validation date Granted from .Certification no Specialization Professional grades
                             
                             
                             
                             
                             
                             
                             
 Training & Professional Qualification -6 ‫ التدريب والتأهيل المهني‬-6
:)Continues professional Development – less than 2 weeks(
:)‫(التطوير المهني المستمر – أقل من أسبوعين‬

:Training Courses & Lectures in Engineering Field -6/1 :‫ دورات أو محاضرات تحصلت عليها في المجال الهندسي‬-6/1

‫عدد الساعات‬ ‫المدة‬ ‫التاريخ‬ ‫المكان‬ ‫جهة التدريب‬ ‫المحاضرة‬/‫الدورة‬

.No. of hrs Duration Date Place Trainer Course/lecture
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   

:Long Term Training Programs (more than 2 weeks) -6/2 :)‫ برامج تدريبية تأهيلية طويلة (أكثر من أسبوعين‬-6/2
‫عدد الساعات‬ ‫المدة‬ ‫التاريخ‬ ‫المكان‬ ‫جهة التدريب‬ ‫مسمى البرنامج‬
.No. of hrs Duration Date Place Trainer Program name
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   

:Training Courses & Lectures in Personal Skills -6/3 :‫ دورات أو محاضرات تدريبية تلقيتها في المهارات الشخصية‬-6/3
‫عدد الساعات‬ ‫المدة‬ ‫التاريخ‬ ‫المكان‬ ‫جهة التدريب‬ ‫المحاضرة‬/‫الدورة‬
.No. of hrs Duration Date Place Trainer Course/lecture
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   
                                   

:Training & Lecturing Engineering Courses -6/4 :‫ تدريب مهندسين أو محاضرات علمية ومهنية‬-6/4

‫الشهادة‬ ‫عدد المتدربين‬ ‫الفئات المستهدفة‬ ‫المدة‬ ‫المكان‬ ‫مركز التدريب‬ ‫المحاضرة‬/‫الدورة‬
Certificates No. of trainees Type of attendance Duration Place Training center Course/lecture
                                          
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         

:Membership with Professional Organization & Associations -4 :‫ عضويات في هيئات وجمعيات مهنية‬-7
‫تاريخ الصالحية‬ ‫الموقع‬ ‫رقم التسجيل‬ ‫التخصص‬ ‫اسم الجهة‬
Validation date Place .Certification no Specialization Name
                             
                             
                             
                             
                             
                             
                             
                             
                             
                             

:Scientific & Professional Participations -8 :‫ المشاركات العلمية والمهنية‬-8

:Scientific Researches, Studies & Technical Reports -8/1 :‫ الدراسات واألبحاث والتقارير واألوراق العلمية‬-8/1

‫التاريخ‬ :‫مقدم إلى‬ ‫النوع‬ ‫الموضوع‬ ‫العنوان‬

Date :Presented to Type Subject Title
                             
                             
                             
                             
                             
                             
                             
                             
                             
                             
                             
                             

:Professional & Scientific Committees -8/2 :‫ اللجان المهنية والعلمية‬-8/2

‫المدة‬ ‫التاريخ‬ ‫المكان‬ ‫الموضوع‬ ‫العنوان‬

Duration Date Place Subject Title
                             
                             
                             
                              
                             
                             
                             
                             

: Engineering Work Teams -8/3 :‫ فريق عمل هندسي‬-8/3

‫المدة‬ ‫التاريخ‬ ‫المكان‬ * ‫نوع المشاركة‬ ‫العنوان والموضوع‬

Duration Date Place Type of participation Title & Subject
                             
                             
                             
                             
                             
                             
                             
Workshop management‫ إدارة ورش عمل‬Supervision (3) ‫ إشراف‬Design (2) ‫تصميم‬ )1( *

:Engineering Conferences & Seminars -9 :‫ المؤتمرات والندوات الهندسية‬-9

‫المدة‬ ‫التاريخ‬ ‫الموقع‬ * ‫نوع المشاركة‬ ‫العنوان‬
Duration Date Place Type of participation Title
                             
                             
                             
                             
                             
                             
                             
                             
                             
6.‫ تنظيم‬Organization 5. ‫ إدارة[ حلقة نقاش‬Work shop head 4.‫ متحدث رئيسي‬Key speaker 3.‫ رئاسة جلسة‬session head 2. ‫ قديم ورقة‬Presenting paper * 1. ‫ حضور‬Attendance

:Engineering Arbitration -10 :‫ التحكيم الهندسي‬-10

‫التاريخ‬ ‫الموقع‬ :‫مقدم إلى‬ * ‫نوع التحكيم‬ ‫الموضوع‬
Date Place :Presented to Type of arbitrations Subject
                             
                             
                             
                             
                             
                             
Arbitrating technical disputes ‫ حتكيم قضايا ومنازعات‬Arbitrating engineering competitions )3( ‫ حتكيم مسابقات معمارية‬Arbitrating technical papers )2( ‫*حتكيم أوراق علمية‬ )1(

: Engineering or Research Teams Leadership -11 :‫ قيادة عمل أو بحث هندسي‬-11

‫التاريخ‬ ‫المدة‬ * ‫نوع المشاركة‬ ‫الموضوع‬ ‫العنوان‬
Date Duration Type of participation Subject Title
                             
                             
                             
                             
                             
                             
                             
                              
                             
                             
Project management(more than 1 year) )‫ إدارة مشروع (ال تقل عن سنه‬Leading research team )3( ‫ قيادة فريق حبثي‬Leading engineering work )2( ‫*قيادة فريق عمل هندسي‬ )1(

Other Works & Activities -12 ‫ أعمال وأنشطة أخرى‬-12

Voluntary professional activity, engineering writing, ( ،‫ ب راءات إخ تراع‬،‫ مؤلف ات هندس ية‬،‫(أنش طة تطوعية مهني ة‬
:).… ,professional award, thanks & appreciation :).... ،‫ شهادات شكر وتقدير‬،‫جوائز وأوسمه‬

‫التاريخ‬ :‫مقدم إلى‬ ‫النوع‬ ‫الموضوع‬ ‫نوع النشاط‬

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- Please print or write clearly. .‫ الرجاء تعبئة النموذج طباعة أو بخط واضح‬-
- Attach a copy of all certificates and documents needed
for evaluation
.‫ إرفاق صورة عن جميع الشهادات واألوراق والمستندات الخاصة بالتأهيل‬-
- If necessary, attach extra papers & mention the no. on ‫ في حالة الحاجة لمزيد من المساحة ترفق أوراق إضافية ويشار فيها إلى رقم‬-
each supplement. .‫الحقل‬

:Name       :‫االسم‬

:Date       :‫التاريخ‬ :Signature :‫التوقيع‬

 Letter of Authorization and Confirmation ‫خطاب إقرار و تفويض‬

I hereby authorize the Saudi Council of Engineers

or its authorized affiliates, agents and subsidiaries, ‫أنا الموقع أدن اه أف وض الهيئة الس عودية للمهندس ين أو من‬
acting on its behalf to verify information, ‫ للتحقق نيابة ع ني عن المعلوم ات والوث ائق‬،ً‫تفوضه رس ميا‬
documentation and background verification
presented on my application form including but ‫ والخ برات‬،‫المرفقة بطل بي بما في ذلك الش هادة العلمية‬
not limiting to education, professional
qualification, registration and employment
.‫والمؤهالت المهنية والوظيفية‬
I hereby grant the authority for the bearer of this
letter, with immediate effect, to release all
،‫وبموجب هذه التفويض أمنح الصالحية لحاملي هذا الخطاب‬
necessary information to the Saudi Council of ‫لتس ليم جميع المعلوم ات الخاصة بي للهيئة الس عودية‬
Engineers or its authorized affiliates, agents and .‫للمهندسين أو من تفوضه‬
subsidiaries.
This information / documentation may contain but ‫ وتواريخ‬،‫وتشمل المعلومات والوثائق المطلوبة على الدرجات‬
is not limited to grades, dates of attendance, grade
point average, degree / diploma certification, ،‫ والدرجة أو الش هادة العلمية‬،‫ والمع دل ال تراكمي‬،‫الدراسة‬
professional certification, employment title,
employment tenure, licensing and registration and ‫ والترخيص‬،‫ ومدة الخدمة‬،‫ والعمل الحالي‬،‫والشهادات المهنية‬
any other information deemed necessary to ‫والتس جيل وأية معلوم ات أخ رى ض رورية إلج راء التحقق من‬
conduct the verification of the information /
documentation provided. .‫المعلومات والوثائق المقدمة‬
I hereby release all persons or entities requesting
or supplying such information from any liability ‫وأقر ب أن أخلي مس ؤولية جميع األش خاص أو الجه ات الطالبة‬
arising from such disclosure. I am willing that a
photocopy of this authorization be accepted with
.‫له ذه المعلوم ات من أي مس ؤولية قانونية قد تنشأ عن ذل ك‬
the same authority as the original. I further .‫وأوافق على أن تك ون ص ورة ه ذا الخط اب مثل األصل‬
understand and acknowledge that this Information
Release Form will remain valid for a period of ‫وإق راري ه ذا ص الح إلى م دة س نتين من بعد الحص ول على‬
two years following its completion. .‫المعلومات المطلوبة‬
I certify that all information provided to Saudi
Council of Engineers are correct, I bear the ،‫كما أقر بأن جميع المعلومات والوثائق المسلمة للهيئة صحيحة‬
responsibility otherwise.
.‫وأتحمل كامل المسئولية إذا أتضح خالف ما ذكر‬

First Name Middle Name Last/Surname ‫اسم العائلة‬ ‫اسم األب‬ ‫االسم األول‬

Signature Date ‫التاريخ‬ ‫التوقيع‬