INSTITUTION OF ENGINEERS (Mauritius) Established 1948 Form of Application (Student Member)

1. Applicants Particulars Mr/Mrs/Miss Surname Address Nationality Tel no. Fax no. E-mail Other Names & Initials Date of Birth

2. Applicants Qualifications 2.1 Cambridge HSC / London GCE / Baccalaureate Name of School Examination Year Subjects Results

2.2 Applicants Enrolment in an Undergraduate Degree / Diploma Course in Engineering or Related Subject Name and address of : University / Institution Title of Course (e.g BEng. (Hon) Civil Engineering) Duration of Course Year of Admission Level / Year of Course completed

INSTITUTION OF ENGINEERS (Mauritius) Established 1948 Form of Application (Student Member)

An academic staff of the above University/Institution must certify that the above information is correct. Academic Staff

Name Department Position Staffs Signature Date

3. Declaration

I, the Applicant, declare that the information contained herein is correct, and further declare that upon my admission as a Student of the Institution, I shall conduct myself in accordance with the Rules of the Institution. Signature Date

4. Space for Institutions use only

Received: Acknowledged: Membership Committees Decision: Councils Decision: