FORMULIR APLIKASI

ASEAN CHARTERED PROFESSIONAL ENGINEER

INDONESIA MONITORING COMMITTEE

2015
 APP 01

APPLICATION FOR A PROFESSIONAL ENGINEER TO BE

REGISTERED AS ASEAN CHARTERED PROFESSIONAL ENGINEER
(ACPE)
(To be completed by Applicant in BLOCK LETTERS with BLUE INK)

Name:
Name to be put in the certificate:
Address:

Tel . No.: Fax. No.:

E-mail:
Identity Card No.: Date of Birth:
First Degree / University:
Discipline of Engineering:
Graduate Engineer Registration No.:
Date of Registration:
Professional Engineer Registration No.:
Date of Registration:
Branch of Engineering:

Discipline for ACPE Registration (select 1 discipline only):

Mechanical Eng. Electrical Eng. Chemical Eng. Physics Eng.
Aeronautical Eng. Marine Tech Industrial Eng. Environmental Eng.
Petroleum Eng. Mining Eng.
Civil Eng.
Structural Geotechnical Water Transportation
Resources
I enclose herewith * money order / bank draft / cheque no. :
for the amount of Rp. being the fee.

Date of previous application:

(Write NIL if not applicable)
Date:
( )
*delete whichever is not applicable (signature)

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 APP 02

PORTOFOLIO FOR THE APPLICATION AS ASEAN CHARTERED PROFESSIONAL ENGINEER

Name:

PROFESSIONAL EXPERI ENCE IN RESPONSIBLE CHARGE OF SIGNIFICANT ENGINEERING WORK

A B C EXPERIENCE AREA (in months) E

Total
D1 D2 D3 D4 D5
Signature of any

graduates / study /
professional engineers

research / teaching Masters / post

Date (month State concisely title of position held, name of employer, Name, who has personal

worksOther engineering
& year) knowledge of applicants

managementPlanning /
location and description of each work (make statement position and
relating to brief and concise, designating each work upon which address of training or experience in

officeDesign /
each the period mentioned

Site / field
engaged with or change of position separately: include professional
appointment some indication of magnitude and complexity of work in engineer
which engaged, your duties and degree of responsibility) under whom
Example: April
served &
87 to January
97
(if necessary additional sheets may be attached) contact no.

Position:
Name of employer:
Client:
Project title:
Location:
Project description:
Job description & responsibilities:

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 APP 02

PROFESSIONAL EXPERI ENCE IN RESPONSIBLE CHARGE OF SIGNIFICANT ENGINEERING WORK

A B C EXPERIENCE AREA (in months) E

Total
D1 D2 D3 D4 D5
Signature of any

graduates / study /
professional engineers

research / teaching Masters / post

Date (month State concisely title of position held, name of employer, Name, who has personal

worksOther engineering
& year) knowledge of applicants

managementPlanning /
location and description of each work (make statement position and
relating to brief and concise, designating each work upon which address of training or experience in

officeDesign /
each the period mentioned

Site / field
engaged with or change of position separately: include professional
appointment some indication of magnitude and complexity of work in engineer
which engaged, your duties and degree of responsibility) under whom
Example: April
served &
87 to January
97 (if necessary additional sheets may be attached) contact no.

Total
(If necessary insert additional rows above)
Months

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 APP 03

DECLARATION FOR THE APPLICATION AS ASEAN CHARTERED

PROFESSIONAL ENGINEER

I hereby declare that:

I have had years of practical experience in engineering.

YES NO

I am a Professional Engineer

I meet the entire requirement as stated in Article 3 of the

ASEAN Mutual Recognition Arrangement (MRA)

No disciplinary action have been taken against me

I am not a bankrupt

Others:

I declare that I have not submitted any other application to the Monitoring Committees of any
other ASEAN Member State for registration as ACPE.

Yours Sincerely,

(signature)

Name:

PE Reg. No.:

Date:
Note: Please tick () in the relevant box.

rev 03 Page 4 of 3