PICHE (Pakistan Institute of Chemical Enginners)

Membership Form

*Class of membership applied for:

*Name in full (Block Letters):

*Date of Birth:

*Nationality:

*Residence Address:

*Office Address:

*Preferred Mailing Address Off/Res:

*Tele. No. Off:

*Tele. No. Res:

*Mob. No.:

*Email:

*Password:

*Past and present membership of PIChE with number (if any):

*Membership of other Professional Bodies:

Engineering/Technical Education:

*Degree/Diploma:

*Subjects:

*Year:

*College/Institution:

*Description of Post-graduate research/degree (if any):
(Please state degree, year and Institution)

General Education:

*Degree/Diploma:

*Year:

*College:

Professional History

(Begin with present work backward give separate details of your experience with each change n responsibilities. Use additional sheet if required).

1) Employer:

From:

To:

Experience Years:

Month:

Job Title:

to whom do you report:

Nature of duties/responsibilities:

2) Employer:

From:

To:

Experience Years:

Month:

Job Title:

to whom do you report:

Nature of duties/responsibilities:

3) Employer:

From:

To:

Experience Years:

Month:

Job Title:

to whom do you report:

Nature of duties/responsibilities:

4) Employer:

From:

To:

Experience Years:

Month:

Job Title:

to whom do you report:

Nature of duties/responsibilities:

REFERENCES

List four responsible persons who have first hand knowledge of your work experience. Atleast two of them should be Corporate Members of PIChE.

No.	Name	PIChE Membership No.
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