SCHEDULE 1 FORM A REV. 1/09 REGULATIONS 2,3,4 AND 5

THE PROFESSIONAL ENGINEERS REGISTRATION BOARD APPLICATION FORM FOR REGISTRATION

1. Applicant’s Details

Title First Name Middle Initials Surname

Place of Birth Country of Birth Date of Birth Nationality

Home Address

Telephone No. Mobile E-mail.

Job Title Employer’s Name

Work Address

Telephone No. Fax E-mail.

Please specify the address you would like all correspondences to be sent to

Home Work

2. Registration Category

Please indicate type of registration being applied for

PE This application is made under Section 9 of the Professional Engineers Registration Act being a person eligible for registration as an Engineer.

SR This application is made under Section 10 (1) of the Act being a person eligible for Special Registration..

TR This application is made under Section 11 (1) of the Act being a person eligible for Temporary Registration.

Please indicate category/categories of engineering

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08

09

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Civil

Chemical

Electrical

Industrial

Mechanical

Structural

Mining

Electronics

Agricultural

Aeronautical

Environmental

Bio-Medical

Metallurgical

Marine

Sanitary

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3. Proposer’s Details

We, the undersigned, propose this person from personal knowledge as a person in every respect worthy of consideration for registration in the category indicated above.

1) Professional Engineer

First Name Surname

Address for Communication

Telephone No. Mobile E-mail.

Signature

Registration No.

 

Stamp / Seal

Verifying Initial

2) Justice of the Peace

First Name Surname

Address for Communication

Telephone No. Mobile E-mail.

Signature

Parish / Number

 

Stamp / Seal

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4. Education

Please provide details of engineering or technology qualifications.

Degree / Award Date Conferred University / College

Name & Location

Dates of

Attendance

Brief Detail of Course

Verifying

Initials

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

5. Practical Training

Please provide details of post-graduate training or other apprenticeship.

Period Organization Name & Location

Brief Description of Training From To

         

         

         

         

         

         

         

         

         

Verifying Initials

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6. Work Experience

Please provide details on applicable working experience in the space below or attach detailed C.V..

Period Organization Name and Location  

Position Held   Description of Work Done  From To

           

           

           

           

           

           

           

           

           

           

           

           

           

           

Verifying

Initials  

7. Membership of Professional Bodies

Professional Body Professional Service Verifying Class of Date

         

         

         

         

         

         

         

         

         

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8. Declaration

Please provide a current passport size photograph signed by a Justice of the Peace.

Affix signature to this declaration and submit along with the required fee to the Registrar, The Professional Engineers Registration Board.

I, _____________________________________________ declare that the statements made on this application form are true and complete in all respects.

I have obtained a copy of, have read and agree to abide by the Professional Engineers (Code of Professional Conduct) Rule 2004. I further agree that upon registration I will pay the required fees and abide by the regulations of the Board.

Signature Date

OFFICIAL USE: Application No:

Date Received: __________________________________

Documents Received:

Verification of Originals:

Comments:

FORM A REV. NO: 1- 2009