FORM A

REGISTRATION OF ENGINEERS ACT 1967

REGISTRATION OF ENGINEERS REGULATIONS 1990
(Regulation 16)

APPLICATION FOR REGISTRATION AS A GRADUATE ENGINEER

PERSONAL DETAILS
Reference No.
Name
Title
Gender
Date of Birth
Place of Birth
Citizenship
New IC No
Old IC No
Address

: JS 129500
: MUHAMMAD 'IZZAD AFIF BIN NORDIN
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: 901222105157
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:

Postcode / City
State
Country
Tel No.
Mobile No
Fax No
Email (1st)
Email (2nd)
Academic Qualification
Professional Qualifications/Training (if any)

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: izzadafif@gmail.com
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:

ACADEMIC QUALIFICATIONS
Name of Certificate/Diploma/Matriculation/ A Level
Name of Institute/College
Year of Study
Name of Degree
Engineering Course
University
Campus
Country
Period of Study
Year of Study
Mode of Study

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: To
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: years
: to
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Other Qualification (if any)

University/College

Degree

Course
-- no record --

Engineering Disciplines

Country

Year Intake

Year Award

SUPPORTING DOCUMENTS / ATTACHMENTS

Photo
Document

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PAYMENT
Payment Type
Bank Code
Payment Ref.
Certificate Delivery Method
Subscribe BEM's official magazine - The Ingenieur
Amount

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: 0.00

DECLARATION TO BE SIGNED BY THE APPLICANT

The Registrar,
Board of Engineers Malaysia
I, the undersigned, apply for registration as a Graduate Engineer and declare as follows:
I am a Malaysian citizen.
I am a Permanent Resident of Malaysia.
I am not a bankrupt.
The particulars given in this form and the certificates attached are true and correct.
I agree to abide by the Registration of Engineers Regulations 1990, including the Code of Professional Conduct

Date .............................................................

.............................................................
(Signature of Applicant)

Section 24(a) of the Registration of Engineers Act 1967: "Any person, sole proprietorship, partnership or body corporate who procures or attempts to
procure registration or a certificate of registration under this Act by knowingly making or producing or causing to be made or produced any false or
fraudulent declaration, certificate, application or representation whether in writing or otherwise, shall be guilty of an offence and shall, on conviction, be
liable to a fine not exceeding ten thousand ringgit in the case of an individual, or fifty thousand ringgit in the case of a sole proprietorship, partnership or
body corporate, or to imprisonment for a term not exceeding three years, or to both.".