PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC

7/F, Unit 703 Futurepoint Plaza 1 Condominium,

112 Panay Avenue, Quezon City
Tel/Fax No. (02) 398-1434
Cell Nos. Globe +63 9173152765  Smart +63 9283410623  Sun +63922302229
Email address: picenatl@pice.org.ph  Website: pice.org.ph

STUDENT MEMBERSHIP REGISTRATION FORM

STUDENT CHAPTER PHINMA Araullo University

MOTHER CHAPTER Nueva Ecija University of Science and Technology

ENROLLED IN YEAR School Year 2021-2022

LAST NAME FIRST NAME MIDDLE NAME

HOME ADDRESS

DATE OF BIRTH: PLACE OF BIRTH: STATUS:

TEL. NO. CELL NO.

EMAIL ADDRESS:

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.

Signature:

Endorsed By: (School Chapter) PHINMA Araullo University

Student Chapter Adviser: Engr. Karen Kenneth Ricamonte

Student Chapter President: John Mark Aquino

Date Submitted: Membership No:

(Year-Charter No. – Membership No.)