You are on page 1of 2

M E M B E R S H I P No.

)
e SC
f th (EC
o er Engineering College Abbreviated form of the Branch Code Membership
hip apt PIN Code Number Engineering College Name Serial Number
rs h
be ts C (Above portion to be filled in by the Adviser of the Chapter)
m
e en
r M ud
fo e St
n g
tio lle
il ca Co The Institution of Engineers ( India)
in
p g
Ap erin
e 8, GOKHALE ROAD, KOLKATA 700 020 ECSC
E ng

The Secretary & Director General Date ...............................


The Institution of Engineers (India)
8, Gokhale Road, Kolkata 700 020

Dear Sir,
I hereby apply for enrolment as a member of the Students Chapter of The Institution of Engineers (India) in accordance with
the rules of the Chapter and the Bye-laws and Regulations as they now stand or hereinafter be legally altered. I do hereby undertake
that I will be governed by the Bye-laws and Regulations of the Institution. I accept the responsibility for the accuracy of the particulars
contained in the bio-data given overleaf and I agree that, if I am enrolled, the validity of the enrolment shall depend upon the accuracy
of the particulars as required under the Bye-laws. I also undertake to abide by the conduct of rules and/or Code of Ethics that the Council
may prescribe from time to time.
NAME (in block letters)

.................................................................................................. ...............................................................................
Branch of Engineering Signature of the Applicant (in English only)
FOR USE OF HEADQUARTERS OFFICE ONLY
His/Her application is recommended/not recommended for
M E M B E R S H I P No. membership of the Engineering College Students Chapter.

Engineering College Abbreviated form of the Branch Membership


Recommended Not recommended
PIN Code Number Engineering College Name Code Serial Number
(Above portion to be filled in by the Adviser of the ............................................................................................................
Dealing Officer (HQ)
Subscription Received Initial
Rs...................................... for ..................................... received on ..................................................... ....................................................
(Ist - IVth Year)
Rs...................................... for ..................................... received on ..................................................... ....................................................
(IInd - IVth Year)
Rs...................................... for ..................................... received on ..................................................... ....................................................
(IIIrd & IVth Year)
Rs...................................... for ..................................... received on ..................................................... ....................................................
(IVth Year)
This portion to be retained by the Chapter This portion to be retained by the Student

M E M B E R S H I P No. M E M B E R S H I P No.

Engineering College Abbreviated form of the Branch Membership Engineering College Abbreviated form of the Branch Code Membership
This portion to be retained by the Student

PIN Code Number Engineering College Name Code Serial Number PIN Code Number Engineering College Name Serial Number
(Above portion to be filled in by the Adviser of the Chapter) (Above portion to be filled in by the Adviser of the Chapter)

Name .......................................................................... The Membership Card is issued to


Branch ........................................................................
First/Second/Third/Fourth Year (tick here) Affix Passport as STUDENT of the Institution and is valid up to the year of
Roll No. ...................................................................... Size Photograph his/her completion of study at the Engineering College subject
to renewal each year.

Signature of the Student For Secretary & Director General


Signature of the
Signature of Adviser Student Signature of Adviser with Seal
P.T.O.
BIO-DATA
1 NAME

2 Fathers Name / Husbands Name

3 Mailing Address

PIN
4 Permanent Address

PIN
5 E-mail id/Mobile No. :

6 Date of Birth :
D D M M Y Y Y Y
7 Age (as on the day
of Application) :
Y M
8 Nationality :
9 Details of Examination Passed :
Examination Examination Authority Roll /Registration No. Year of Passing

10 At present studying at : I certify the application for consideration to induct the applicant in IEI
(i) .................................................. Engineering College fold as an ECSC Member of IEI.
(ii) Address.........................................................................
.......................................................................................
(iii) Semester ...................... Roll/Registration No ................. (Signature of the Adviser of the Engineering College Students Chapter
(iv) Branch........................................................................... with seal and date)

The Institution of Engineers ( India)


Received
Engineering College Students' Chapter

on

8, GOKHALE ROAD, KOLKATA 700 020


Fee Structure for Members of

Amount

250.00
190.00
130.00
70.00
(Rs.)

IIIrd & IVth Year


IInd - IVth Year
Ist - IVth Year

IVth Year
Period

IEI MEMBERSHIP CARD