APPLICATION FORMAT FOR CHARTERED ENGINEER CERTIFICATE The Director (Membership) The Institution of Engineers (India) 8 Gokhale Road Kolkata 700 020 Dear Sir, You are requested to consider my application for issuing Chartered Engineered Certificate. I give below the following factual information as marked ( )in the appropriate box. 1. Ihave not applied for Chartered Engineer Certificate earlier. Therefore, an amount ® 7500/US § 750 is being paid by Demand Draft (DD)/cash/online. Details are given below 2. Lhad applied for Chartered Engincer Certificate earlier and received the same. Please find enclosed photo copy of the certificate, Therefore, an amount of € 2,000.00/ US $ 200 is being paid by Demand Draft (DD)/cash/online, Details are given below. Thereby confirm that I am entitled for Chartered Engineer Certificate as [ have compounded by annual subscription for life/made full payment of the Composite Subscription as Clause 69(vi) of the Bye-Laws of The Institution of Engineers (india) ‘My Membership Grade and Number is AM/M/F |— Full Name (Block Letters) * Address (Block Letters) Phone/Mobile No... Ful Signature with Date Enclosures : As tick marked (¥ ) below. Tam enclosing following documents for your kind consideration [tick (¥) appropriate box] AsperSerialNo:1above Demand draft of & 7500 (US $ 750 for members residing in abroad) (Draft No. of The Institution of Engineers (India), payable at Kolkata ) in favour Paid % 7500.00 online vide reference no. and payment geteway ID/ ‘Transaction ID. AsperS 2ahove Demand draft of € 2000.00 (US $ 200 for members residing/working in abroad) (Draft no, ) in favour of The Institution of Engineers (India) payable at Kolkata, Paid % 2000.00 online vide reference no. Transaction ID. a and payment geteway ID/ Chartere Photocopy oft “The Certificate will be sent to the address as recorded in our database. For any change in the address, please login to our website to update your address or apply for the same, Form No. MEMB/10 ew 0770062046