application form for admission[1]

8/8/2019 Application Form for Admission[1]

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INDIAN INSTITUTION OF INDUSTRIAL ENGINEERINGSector-15, Plot 103, CBD Belapur, Navi Mumbai-400 614.

Tel.: 2756 2562, 2757 9412 Telefax : 022-27578526

Web : www.iiie-india.com

E-mail : [email protected]

A PPL I C A T I O N FO R A D M I S S I O N T O S T U D E N T M E M B E R S H I P

(The duly comleted application form should be sent to the Controller of Examinations at the

above address. True copies of certificate should be attested by a Corporate Member of IIIE or aGovt. Gazetted Officer or Notary. Incomplete application will be returned)

I. NAME OF THE APPLICANT FIRST MIDDLE LAST

(In block letter)

II. DATE OF BIRTH Date Month Year

(Enclose an attested true copy of School Leaving Certificate)

III. QUALIFICATIONS [Give details of the qualifications obtained after SSC (X std.)]

Refer to General Information and Scheme of Examination for rules relating to minimum qualifications required for admission.

Enclose an attested true copy of Certificate in proof of qualifications. Marklists are not acceptable in place of Degree/Diploma

Certificate.

Qualifications

Mention the full

title as well as the

abbreviation of each

qualification

Name of University

Institution/Board/

Professional body

(Name of the

Examining body)

Minimum entry

qualification and

duration of the course

in years

Subject/s

Main /

Major

Subsidiary

Month & Year of

Passing

a.

b.

c.

d.

IV. WORKING EXPERIENCERefer to General Information and Scheme of Examination for rules relating to munimum period of working experience requiredfor admission. (Applicant should produce a Service Certificate for his/her employer/s stating the period of employment and the

nature of duties and responsibilities of the job along with the application).

Working Experience - Details in Chronological order Starting with the latest position held

a.

b.

c.

d.

Name & Address of the EmployerDesignation of

the post held

Nature of the duties and

responsibilitiesperiod

From To

V. Name, designaon and full address of the Gazetted Officer or IIIE member or Notary attesting the certificates and photographs

Name

Designation

I.I.I,E. Membership No.

Address

Tel No.

VI. ADDRESS OF THE APPLICANT

Permanent * Present

Pin Pin

Tel. No. Tel. No.

E-mail: E-mail:

(Photo of the applicant)(i) One recent copy of yourpassport size (4.5. x 4 cms)Photograph should be affixedhere(ii) One copy of the same pho-tograph should be affixed toIdentity Card.(iii) Both Photographs should

be attested by a CorporateMember of IIIE or a Govt.Gazetted Officer. or a Notary.

INDIA

NIN

ST

ITUTIONOFINDUSTR

IAL

E

NGIN

EERING


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VII A crossed Demand Draft bearing No................................... dated.....................................for Rs.......................................

drawn in favour of Indian Institution of Industrial Engineering. Payable at Mumbai is enclosed towards Admission fees.

Subscription for Membership Identity Card, Exemption fees, cost of Question paper sets,etc. (Please tick mark () the itemstowards which the amount is remitted).

VIII. DECLARATION

I, the unersigned, hreby declare the above statements to be correct and hereby agree that in the event of my being admitted as a

Student Member, and as long as I continue to hold that Membership, I will be bound by and observe the provisions of the

Memorandum of Association, Rules and Regulations of the Indian Institution of Industrial Engineering as they exist now or as

they may hereafter be modified from time to time and that I will endeavour to further the objectives of the Institution.

Place : __________________________

Date: ___________________________ APPLICANTS SIGNATURE

FOR OFFICE USE ONLY

A. DOCUMENTS ATTACHED/ B. FEES RECEIVED

in Support of : Towards

a. Age Admission Fee Rs.______________

b. Qualifications Subscription for Membership Rs.______________

c. Experience (Subsequent to

qualifying Exam) Identity Card Rs.______________

d. Claim for exemption Exemption Fees Rs.______________

Miscellaneous Rs.______________

c. Admitted under Regulation No. 3.6 A QP Set (s)

Prel./Scc.A/Sec.B

VIDE MEMBERSHIP NUMBER Syllabus Rs.______________

S._______________ ( ) with Advance Rs.______________

EFFECT FROM : ___________________ / 200 Total Rs.______________

Date :_____________________ Assistant Controller of Examinations

DESPATCH PARTICULARS

a. Admission Letter_______________________________ e. QP (sets) ______________________

b. Exemption Certificate____________________________ f. ______________________________

c. Identity Card__________________________________ g. ______________________________

d. Receipt No.___________________________________ h. ______________________________


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APPLICATION FOR EXEMPTION

FROM PRELIMINARY / SECTION A EXAMINATION PAPERS/STo,

The Chairman

Board of Examinations

I.I.I.E., CBD, Belapur,

NAVI MUMBAI - 400 614.

Sir,

I wish to apply for exemption from the following papers(s) of Preliminary / Section A Examination on the basis of my

having passed the following Examination/s.

Name of the Examination

(Full Title as well as its

abbreviation)

Diploma .................................................................................

................................................................................................

Degree ..................................................................................

Post Graduate Degree.........................................................

................................................................................................

PRELIMINARY SECTION A

Code Title Code Title

1

2

3

4

5

6

* Attested true copy/ies of the above Diploma/Degree/Post Graduate Degree Certificate/s is / are enclosed.

DETAILS OF DEMAND DRAFT

No. ......................................................

Drawn on ................................................................................................................................................................Bank for

Amount Rs. .................................................................................................................Dated ................................towards

fees for exemption drawn in favour Indian Institution of Industrial Engineering, Navi Mumbai is/are enclosed

Yours faithfully

Membership No. _________________

Date : _______________ Signature of Applicant

Name _____________________

* Original Marklists should not be submitted unless specifically asked by the Board of Examinations.

Attestation should be by a Corporate Member / Gazetted Officer / Notary.

Examining authority / Body

(University / Board / Institute

recognized professional body).

...........................................................................................................................

................................................................................................................

.........................................................................................................

.........................................................................................................

1

2

3

4

5

6


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FOR OFFICE USE ONLY

Name of the Student Member

Membership Number

Date of Receipt of Application for Exemption

Application Fees & Receipt No.

Exemption permissible under Rules

I

Preliminary

1. IE 001 2. IE 002 3. IE 003

4. IE 004 5. IE 005 6. IE 006

II

SECTION - A

1. IEA 01 2. IEA 02 3. IEA 03

4. IEA 04 5. IEA 05 6. IEA 06

7. IEA 07 8. IEA 08

Remarks : 1. The permissible Exemption(s) may be granted.

2. Claim needs review

Date :

Assistant Controller of Examinations


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IndianInstitutionofIndustrialEngineering

39

To be completed by the applicant

AffixPassport

Size Photohere

Name

Signature

(Complete Reverse side also)

ATTESTED BY ME

Name

Signature

Address

Seal

To be attested by a CorporateMember of IIIE or a Govt.

Gazetted Officer or Notary.

IDENTITY CARD

INDIAN INSTITUTION

OF

INDUSTRIAL ENGINEERINGNational Headquarters :

Sector 15, Plot 103, CBD BelapurNavi Mumbai 400 614.

Tel. : 2756 2562, 2757 9412 Telefax : 022-27578526E-mail : [email protected]


Name

Full Address

(Reverse side also to be completed)

For Office Use

Student Membership No.. : S. ( )

Date of Admission

Controller of Examinations


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IndianInstitutionofIndustrialEngineering

40

IDENTITY CARD

INDIAN INSTITUTION

OF

INDUSTRIAL ENGINEERINGNational Headquarters :

Sector 15, Plot 103, CBD BelapurNavi Mumbai 400 614.

Tel. : 2756 2562, 2757 9412 Telefax : 022-27578526E-mail : [email protected]


Name

Full Address

(Reverse side also to be completed)

For Office Use

Student Membership No.. : S. ( )

Date of Admission

Controller of Examinations

application form for admission[1]

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