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‫دا‬ ‫ا‬


Letter of Authorization and Confirmation ‫ﺨطﺎب إﻗرار وﺘﻔوﻴض‬

I hereby authorize Saudi Council of Engineers

or its authorized affiliates, agents and
‫أﻧﺎ اﻟﻤﻮﻗﻊ أدﻧﺎﻩ أﻓﻮض اﻟﻬﻴﺌﺔ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﻤﻬﻨﺪﺳﻴﻦ أو ﻣﻦ‬
subsidiaries, acting on its behalf to verify ‫ ﻟﻠﺘﺤﻘﻖ ﻧﻴﺎﺑﺔ ﻋﻨﻲ ﻋﻦ اﻟﻤﻌﻠﻮﻣﺎت واﻟﻮﺛﺎﺋﻖ‬،ً‫ﺗﻔﻮﺿﻪ رﺳﻤﻴﺎ‬
information, documentation and background
verification presented on my application form ‫اﻟﻤﺮﻓﻘﺔ ﺑﻄﻠﺒﻲ ﺑﻤﺎ ﻓﻲ ذﻟﻚ اﻟﺸﻬﺎدة اﻟﻌﻠﻤﻴﺔ واﻟﺨﺒﺮات‬
including but not limiting to education,
professional qualification, registration and
.‫واﻟﻤﺆﻫﻼت اﻟﻤﻬﻨﻴﺔ واﻟﻮﻇﻴﻔﻴﺔ‬
‫وﺑﻤﻮﺟﺐ ﻫﺬﻩ اﻟﺘﻔﻮﻳﺾ أﻣﻨﺢ اﻟﺼﻼﺣﻴﺔ ﻟﺤﺎﻣﻠﻲ ﻫﺬا اﻟﺨﻄﺎب‬
I hereby grant the authority for the bearer of
this letter, with immediate effect, to release all ‫ﻟﺘﺴﻠﻴﻢ ﺟﻤﻴﻊ اﻟﻤﻌﻠﻮﻣﺎت اﻟﺨﺎﺻﺔ ﺑﻲ ﻟﻠﻬﻴﺌﺔ اﻟﺴﻌﻮدﻳﺔ‬
necessary information to Saudi Council of
Engineers or its authorized affiliates, agents .‫ﻟﻠﻤﻬﻨﺪﺳﻴﻦ أو ﻣﻦ ﺗﻔﻮﺿﻪ‬
and subsidiaries.
‫ وﺗﻮارﻳﺦ‬،‫وﺗﺸﻤﻞ اﻟﻤﻌﻠﻮﻣﺎت واﻟﻮﺛﺎﺋﻖ اﻟﻤﻄﻠﻮﺑﺔ ﻋﻠﻰ اﻟﺪرﺟﺎت‬
This information / documentation may contain
but is not limited to grades, dates of attendance, ،‫ واﻟﺪرﺟﺔ أو اﻟﺸﻬﺎدة اﻟﻌﻠﻤﻴﺔ‬،‫ واﻟﻤﻌﺪل اﻟﺘﺮاﻛﻤﻲ‬،‫اﻟﺪراﺳﺔ‬
grade point average, degree / diploma
certification, professional certification, ،‫ وﻣﺪة اﻟﺨﺪﻣﺔ‬،‫ واﻟﻌﻤﻞ اﻟﺤﺎﻟﻲ‬،‫واﻟﺸﻬﺎدات اﻟﻤﻬﻨﻴﺔ‬
employment title, employment tenure, licensing ‫واﻟﺘﺮﺧﻴﺺ واﻟﺘﺴﺠﻴﻞ وأﻳﺔ ﻣﻌﻠﻮﻣﺎت أﺧﺮى ﺿﺮورﻳﺔ ﻹﺟﺮاء‬
and registration and any other information
deemed necessary to conduct the verification of .‫اﻟﺘﺤﻘﻖ ﻣﻦ اﻟﻤﻌﻠﻮﻣﺎت واﻟﻮﺛﺎﺋﻖ اﻟﻤﻘﺪﻣﺔ‬
the information / documentation provided.
I hereby release all persons or entities ‫وأﻗﺮ ﺑﺄن أﺧﻠﻲ ﻣﺴﺆوﻟﻴﺔ ﺟﻤﻴﻊ اﻷﺷﺨﺎص أو اﻟﺠﻬﺎت اﻟﻄﺎﻟﺒﺔ‬
requesting or supplying such information from
any liability arising from such disclosure. I am
.‫ﻟﻬﺬﻩ اﻟﻤﻌﻠﻮﻣﺎت ﻣﻦ أي ﻣﺴﺆوﻟﻴﺔ ﻗﺎﻧﻮﻧﻴﺔ ﻗﺪ ﺗﻨﺸﺄ ﻋﻦ ذﻟﻚ‬
willing that a photocopy of this authorization .‫وأواﻓﻖ ﻋﻠﻰ أن ﺗﻜﻮن ﺻﻮرة ﻫﺬا اﻟﺨﻄﺎب ﻣﺜﻞ اﻷﺻﻞ‬
be accepted with the same authority as the
original. I further understand and acknowledge ‫وإﻗﺮاري ﻫﺬا ﺻﺎﻟﺢ إﻟﻰ ﻣﺪة ﺳﻨﺘﻴﻦ ﻣﻦ ﺑﻌﺪ اﻟﺤﺼﻮل ﻋﻠﻰ‬
that this Information Release Form will remain
valid for a period of two years following its .‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﻄﻠﻮﺑﺔ‬
‫وأﻗﺮ ﺑﺄن اﻟﺸﻬﺎدة اﻟﻌﻠﻤﻴﺔ اﻟﻬﻨﺪﺳﻴﺔ اﻟﺘﻲ ﺣﺼﻠﺖ ﻋﻠﻴﻬﺎ ﻫﻲ‬
And I affirm that the engineering certificate
that I obtained is from an accredited university ‫ﻣﻦ ﺟﺎﻣﻌﺔ ﻣﻌﺘﺮف ﺑﻬﺎ وﻋﻦ ﻃﺮﻳﻖ اﻻﻧﺘﻈﺎم اﻟﻜﻠﻲ وﻟﻴﺴﺖ‬
and as a full-time student, not through
affiliation or correspondence or internet. .‫ﺑﺎﻻﻧﺘﺴﺎب أو اﻟﻤﺮاﺳﻠﺔ أو اﻹﻧﺘﺮﻧﺖ‬
I certify that all information provided to Saudi ‫ﻛﻤﺎ أﻗﺮ ﺑﺄن ﺟﻤﻴﻊ اﻟﻤﻌﻠﻮﻣﺎت واﻟﻮﺛﺎﺋﻖ اﻟﻤﺴﻠﻤﺔ ﻟﻠﻬﻴﺌﺔ‬
Council of Engineers is correct, and I bear the
responsibility otherwise. .‫ وأﺗﺤﻤﻞ ﻛﺎﻣﻞ اﻟﻤﺴﺆوﻟﻴﺔ إذا اﺗﻀﺢ ﺧﻼف ﻣﺎ ذﻛﺮ‬،‫ﺻﺤﻴﺤﺔ‬

First Name ‫اﻷول‬ ‫اﻻﺳﻢ‬ Middle Name ‫اﻷب‬ ‫اﺳﻢ‬ Last/Surname‫اﻟﻌﺎﺋﻠﺔ‬ ‫اﺳﻢ‬

Signature ‫اﻟﺘﻮﻗﻴﻊ‬ Date ‫اﻟﺘﺎرﻳﺦ‬