PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC.

UNIVERSITY OF THE VISAYAS

______________________________________________________________
Name of Student Chapter
CEBU
_______________________________________________
Mother Chapter

STUDENT MEMBER’S REGISTRATION FORM

PICE-MDB-FM-01-05 / Rev.00/Eff. Date: June 2, 2014
VERGARA RACHEL GERASMIO
__________________________________ _________________________________ ______________________________
SURNAME FIRSTNAME MIDDLE NAME
PROPER PAKIGNE, MINGLANILLA, CEBU
Home Address ___________________________________________________________________________
AUGUST 03, 1999 MINGLANILLA, CEBU SINGLE
Date of Birth _______________________________ Place of Birth _________________Status _____________
N/A 09666080004 rachelgerasmiovergara@gmail.com
Tel No. ______________ Cell No. ______________ Fax No. ___________E-mail Address ________________

Enrolled in (Please check) / Third Year Fourth Year Fifth Year

The undersigned hereby applies for admission as Student Member in the Philippine Institute of Civil
Engineers, Inc. and certifies that all statements made in this application are correct, and agrees to conform with the
requirements for membership in the By-Laws, and that I fully understand the conditions of my membership.

Endorsed By: (School Chapter)

__________________________________________________
Chapter Adviser: ENGR. MITCHELLE IAN DORIA Signature
Chapter President: ADELINE BAROMAN Date Submitted: 10/11/2021
Membership No: ________________________________
(Year-Charter No. – Membership No.)

PRINT CLEARLY Form SC 02

 PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC.
______________________________________________________________
Name of Student Chapter
_______________________________________________
Mother Chapter

STUDENT MEMBER’S REGISTRATION FORM

PICE-MDB-FM-01-05 / Rev.00/Eff. Date: June 2, 2014

__________________________________ _________________________________ ______________________________

SURNAME FIRSTNAME MIDDLE NAME

Home Address ___________________________________________________________________________

Date of Birth _______________________________ Place of Birth _________________Status _____________

Tel No. ______________ Cell No. ______________ Fax No. ___________E-mail Address ________________
Enrolled in (Please check) Third Year Fourth Year Fifth Year
The undersigned hereby applies for admission as Student Member in the Philippine Institute of Civil Engineers,
Inc. and certifies that all statements made in this application are correct, and agrees to conform with the requirements
for membership in the By-Laws, and that I fully understand the conditions of my membership.

Endorsed By: (School Chapter)

__________________________________________________
Chapter Adviser: ________________________________ Signature

Chapter President: _______________________________ Date Submitted: ________________________

Membership No: ________________________________

(Year-Charter No. – Membership No.)

PRINT CLEARLY Form SC 02