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 Engineer Certificate. I give below the following factual information as marked ( ) in the appropriate box. 1. I have not applied for Chartered Engineer Certificate earlier. Therefore, an amount of Rs. 5000/ US $ 500 is being paid by Demand Draft (DD) / cash / online. Details are given below. 2. I had applied for Chartered Engineer Certificate earlier and received the same. Please find enclosed photo copy of the certificate. Therefore, an amount of Rs. 2,000.00 / US $ 200 is being paid by Demand Draft (DD) / cash / online. Details are given below. I hereby confirm that I am entitled for Chartered Engineer Certificate as I have compounded my annual subscription for life/ made full payment of the Composite Subscription as per Clause 69(vi) of the Bye-laws of The Institution of Engineers (India). For Office Use Only

My Membership Grade and Number is AM/M/F Full Name (Block Letters) *Address (Block Letters) : :

............................................................................................................ ............................................................................................................ ............................................................................................................ ................................................................ Pin :

Phone / Mobile No : ........................ E-mail :........................................

Full Signature with Date

Enclosures : As tick marked ( ) below.

I am enclosing following documents for your kind consideration [tick ( ) appropriate box]. As per Serial No: 1 above Demand draft of Rs. 5000 (US $ 500 for members residing in abroad) (Draft No. ......) in favour of The Institution of Engineers (India), payable at Kolkata Paid Rs. 5000.00 online vide reference no................... and Payment Gateway ID / Transaction ID.. As per Serial No: 2 above Demand draft of Rs. 2000.00 (US $ 200 for members residing/working in abroad) (Draft no.) in favour of 'The Institution of Engineers (India)' payable at Kolkata. Paid Rs. 2000.00 online vide reference no.....................and Payment Gateway ID/ Transaction ID.............................. Photocopy of Chartered Engineer Certificate issued to me earlier.

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