Please complete all sections of the form.

Once completed, please save a copy and submit this form via email to: membershipapps@cibse.org OR print and post a copy to: Membership Department, CIBSE, 222 Balham High Road, SW12 9BS, UK.

QUALIFICATION ASSESSMENT FORM

Please complete all sections of this application form

and ensure that copies of qualification certificates,
transcript listing subjects you undertook and examination
marks, and synopsis of MSc/PhD thesis (if applicable) are
attached and the required payment is included.

PERSONAL DETAILS

Please note that if you are not already a CIBSE member,

the cost of assessing your qualifications is 40.00.

Date of Birth 28
D D / 08
M M / 83
YY

If you are already a CIBSE member there is no charge.

Title Mr

First Name(s) RAHOOF

Surname MOODOLI
Home address MOODOLI HOUSE

POAT KARIYAD SOUTH

Post code 673316

KERALA, INDIA
Country INDIA

QUALIFICATION ASSESSMENT FORM

Telephone No 0091-490239480

Please indicate whether:

Fax No

New (not previously a member of CIBSE) or,

Email raoofm@gmail.com

Existing member

Mobile No 00918157040328
Grade

Membership Number

Company name GHARNATA CONSULTANT

Please indicate which level of Engineering Council Registration

you are interested in and would like CIBSE to assess your
qualifications against:

ENGINEERS
Work address 2nd
FLOOR, ARAMEX COURIER BUILDING

ABU HAMOUR
Post code 24436

Engineering Technician (EngTech)

DOHA, QATAR
Country QATAR

Incorporated Engineer (IEng)

Telephone No 00974 70354267

Chartered Engineer (CEng)

Fax No
Email mrahoof@gharnata.net
Preferred mailing address

Home

Work

Preferred email address

Home

Work

EDUCATIONAL QUALIFICATIONS
Please list all your post school qualifications below and indicate any exemptions granted and details of any interruptions to your course.
Awards shown must be accompanied by a photocopy of the original certificate countersigned by your Sponsor as having seen the original.
University or
College

CALICUT
UNIVERSITY

Full title of qualifications

gained including
subject area

BACHELOR OF
TECHNOLOGY IN
ENGINEERING, IN
BRANCH
MECHANICAL
ENGINEERING

Date course
commenced

Course
duration

Date
qualification
obtained

Mode of Study

JUNE 2001

4
YEARS

JUNE
2005

F/T

(F/T, P/T, sandwich,

etc.)

Year of entry
to course

(i.e entered in year 1 or

2, 3 due to exemptions)

1ST YEAR

If your qualifications are not accredited for EngTech you will be required to participate in an interview assessment.
QUALIFICATION ASSESSMENT FORM

Page 1 of 2

APPLICANTS DECLARATION

SUBMITTING YOUR ASSESSMENT FORM:

I certify that the information in this application and supporting

documents are correct. I agree that, in the event of my election
to any class of membership of the Chartered Institution of Building
Services Engineers, I will be governed by the provisions of the
Royal Charter and By-laws as they are now formed or as they
may be hereafter altered; that I agree to abide by the Code of
Professional Conduct, which can be found at www.cibse.org/code,
and do all in my power to advance the objects of the Institution;
providing that whenever I shall signify in writing to the Director
of Membership that I wish to withdraw from the Institution,
I shall, after payment of any arrears which may be due by me
at that period, be free from this obligation.

You can submit a printed copy of this form along with

attachments via post or an emailed copy with attachments using
the details below;

Signature Date

RAHOOF
D D / 10
M M / 15
YY
18

MOODOLI

Digitally signed by RAHOOF MOODOLI

DN: cn=RAHOOF MOODOLI, o=GHARNATA
CONSULTANT ENGINEERS, ou,
email=raoofm@gmail.com, c=QA
Date: 2015.10.18 15:28:49 +03'00'

POSTAL ADDRESS
Membership Department
Chartered Institution of Building Services Engineers
222 Balham High Road, London, SW12 9BS, UK
EMAIL ADDRESS
membership-apps@cibse.org
Telephone +44 (0)20 8772 3650 | Fax +44 (0)20 8675 5449
Registered Charity No. 278104
CIBSE HQ USE ONLY:

NB. In the event of it coming to light that information supplied on this form is inaccurate,
CIBSE reserve the right to withdraw membership of the Institution and discipline the
applicant under the Code of Professional Conduct.

FEES
Payment can be made by cheque payable to CIBSE or by completing
the debit/credit card details below:
Please tick:
Mastercard

Visa

Visa/Delta

Maestro

Please note: we do not accept Amex or laser cards

Card Number
Valid from M M / Y Y
Issue Number (For Maestro only)

Expiry Date M M / Y Y

Security Code

Address details card is registered to

Post code
Country
Please debit card to the amount of
Signature of Cardholder

Date

QUALIFICATION ASSESSMENT FORM

DD / MM / YY

Page 2 of 2