PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC.

University of San Jose – Recoletos Chapter

Name of Student Chapter

Cebu Chapter
Mother Chapter

STUDENT MEMBER’S REGISTRATION FORM

PICE-MDB-FM-01-05 / Rev.00/Eff. Date: November 00, 2021
TUBA
_______________ JULLIFER JOSEPH
_______________ OROPEZA
_________________
SURNAME FIRSTNAME MIDDLE NAME

Sitio Poso, Buhisan, Cebu City

Home Address ____________________________________________

07-01-2000
Date of Birth _________________ Cebu City
Place of Birth __________________________________________Single Status
_________________
09453180890 julliferjoseph.tuba.20@usjr.edu.ph
Tel No./Cell No. _______________________ Fax No. _______ E-mail Address
___________________________________________
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Enrolled in (Please check) First Year Second Year 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: PICE - University of San Jose-Recoletos S.C.

Chapter Adviser: Engr. Alexandria Longos and Engr. Evaline Longos Signature
Sept. 14, 2022

Chapter President: Jann Viggo T. Patiño Date Submitted:

____________________

Membership No: ________________________________

(Year-Charter No. – Membership No.)