APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER

Transcription

1 APPLICATION AND REGISTRATION FOR ADVANCED LEVEL ENGINEER (All entries must be computer printed or typewritten) 1. PERSONAL DETAILS APEC ENGINEER ASEAN ENGINEER Title: Prof Dr Eng Mr Mrs Ms Surname: Given Names (in full): Middle Name: Date of Birth: Name of Employer: Please paste/computer print recent (6 mos) passport size (50mm x 50mm) picture with white background. Private Address ( preferred mailing address): Business Address ( preferred mailing address): Postal Code: Country: Postal Code: Country: Ph:( ) Fax:( ) Ph:( ) Fax:( ) Mobile: ( ) 2. EDUCATIONAL/PROFESSIONAL QUALIFICATIONS Academic Degree: University or College: Professional Discipline: PRC Registration No.: Field(s) of Specialization: Date of Graduation: Date of PRC Registration: General Career Objective: 3. MEMBERSHIP I am a member in good standing of the following PTC Regular Council(s) members (please tick): Society of Aerospace Engineers of the Philippines(SAEP) Philippine Society of Agricultural Engineers(PSAE) Philippine Institute of Civil Engineers(PICE) PhiIippine 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)

2 4. PROFESSIONAL EXPERIENCE Inclusive Dates Company Position Main Responsibility 5. SIGNIFICANT ENGINEERING WORK Inclusive Dates Program/Project Clientele Position Main Responsibility I have read Appendix B and other relevant guidelines available and I have provided evidence in my EPR of my professional involvement in the area(s) of practice selected for registration. 6. CONTINUING PROFESSIONAL DEVELOPMENT(please provide supporting documents) Year Attended Name of Provider Units Earned Program Description

3 7. APPLICANT S DECLARATION I certify under penalty of perjury and/or falsification of public documents that all the documents submitted in support 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 Engineering Practice Report are true and correct and I have made claims of acquired competencies in good faith. The report is my own work and is a true representation of my personal competency in written English. I confirm that I have read and that I understand the PTC Code of Ethics and the Code of Ethics of my profession. I agree that, if admitted 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 the PTC and my APO of any matter that may affect my fitness for admission to and continued inclusion in the Advanced Level Engineer Register. In support of my application for registration on the Advanced Level Engineer Register, 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 (CPD) by involvement in activities related to my particular area of expertise; acknowledge that, on renewal of my APO membership, 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 CPD requirements during the period in which I remain registered may be audited at any time; and consent to my business contact details being published in any form associated with my registration as Advanced Level Engineer. Signature: Date: 8. PAYMENT DETAILS Attached is my payment in: Payment received by: Official Receipt No.: Date received: Cash Check Name of Bank: Check No.:

4 APPLICANT S CHECKLIST Full name and date of birth Complete address Covering Letter Curriculum Vitae Copy of Diploma Engineering Practice Report (EPR), with certified qualifications evidence or Qualification Assessment Summary of Activities Claimed as Continuing Professional Education (CPD) PRC Certificate of Registration Valid Professional Identification Card Certification of Membership in Good Standing from Accredited Professional Organization Recent passport size photographs (2 x 2 ), white background with name written at the back This form, duly accomplished, signed Payment Note: 1) Triplicate copies of the accomplished application forms, including copies of all supporting documents must be submitted; Letter-size (8-1/2" x 11" inches) of paper not less than substance 20 (80 gms) thickness shall be used throughout; photocopies of large documents shall be reduced accordingly. Each set shall be submitted in a letter-size folder using clips or fasteners that require no perforations (holes) or adhesives in keeping the individual pages together, to facilitate re-arrangement, reproduction and final binding of the applications by the Assessment Staff during/after the processing of the application. 2) All applications must be orignally-signed by the applicant and shall be delivered or mailed to: Philippine Technological Council 2/F Kalaw-Ledesma Condominium 117 Gamboa St., Legaspi Village, Makati City. ED APPLICATIONS OR COMPUTER-GENERATED SIGNATURES ON THE APPLICATION FORMS WILL NOT BE ACCEPTED.

5 Declaration by Applicant for ASEAN/APEC Engineer DECLARATION (PLEASE ENSURE THAT ALL BLANKS ARE PROPERLY COMPLETED) I,, of legal age, (Applicant s full name) residing at: (Applicant s legal address) do solemnly and sincerely declare as follows: I am an applicant for Advanced Level Engineer. I declare that it is not possible for me to provide independent verification of certain sections of my Engineering Practice Report (EPR). This is due to the following circumstances, which are beyond my control (State circumstances which prevent independent verification and/or the provision of written references): I declare that the information given by me in the sections in my attached application dated is accurate, correct and complete in all relevant details to the best of my knowledge and belief. (Show date EXACTLY as it appears next to your signature on the application form). I also declare that the relevant experience and level of professional responsibility claimed in the application and supporting documents provide a fair and balanced statement, which may properly be taken into account by the Council in assessing my eligibility for Advanced Level Engineer. This particularly applies to the following Units and Elements of my EPR (see also the Table of Contents of EPR). I stand ready for Professional Interview and to respond to any reasonable requests of the Philippine Technological Council (PTC) for explanations or further information in relation to my application. I make this solemn declaration, under pain of penalties provided by the Philippine Technological Council (ASEAN Engineer) or APEC Engineer Register Philippines - National Monitoing Committee(APEC Engineer) for the making of false statements in declarations, conscientiously believing the statements made in this declaration to be true in every particular. I am fully aware and cognizant of the serious nature of making this Declaration and the its ramifications have been explained to me. Signed:.. (Signature of declarant) Declared at this (place) (date) Before me,., residing at. (Name, profession and address in BLOCK LETTERS, of person authorized to certify the Declaration. Please sign above name. )