IEM PI A100

Professional Interview Application Form

Jan 2017
INSTITUSI JURUTERA MALAYSIA (IJM)
The Institution of Engineers, Malaysia (IEM)
Bangunan Ingenieur, Lots 60/62, Jalan 52/4, Peti Surat 223 (Jalan Sultan), 46720 Petaling Jaya, Selangor Darul Ehsan, Malaysia.
Telephone : 603-79684001 / 79684002 Email : sec@iem.org.my Fax No : 603-79577678

A Personal Details

Full
Name :
Nationality : Age : IC No: PPassport No:
Date of Birth
Place of Birth :
DD/MM/YYYY
Contact
Address

State Postcode Country

Home Phone Mobile Email

Preferred Venue for Interview

Please specify your gender: Male Female

Please specify your language: English B Malaysia Please tick one only.

B Current Employment

Employer Job Title

Business Address

County/State Postcode Country

Business Phone Business Email

C Your Expertise
Select the main and sub sectors most relevant to you and your expertise:

Industry Consultancy Construction Project Management Researcher

Manufacturing & Production System Development Operation & Maintenance

Academia Teaching Research

Others _______________________________________________________________
Engineering Discipline :
Date of Registration with BEM :

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 IEM PI A100
Professional Interview Application Form
Jan 2017

D Tertiary Education

Start Date End Date Course / Qualification Title Institution of Higher Learning Degree Awarded

E Professional Development or Training Schemes (if applicable)

Training Training Description / Accreditation

Competencies Gained
Period Training Institution number

F Professional Services, Papers Presented, Patents Gained, etc.

Date Title

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 IEM PI A100
Professional Interview Application Form
Jan 2017

G Organisation Chart / Accountability Diagram

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Professional Interview Application Form
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H Relevant Career History

Endorsement
By
Start / End Employer, Job Title &
Experience ( Areas of Competencies ) Proposer/Secon
Date Supervising Engineer
der (Supporters)
or Equivalent

Note: (1) The information provided above will be used to carry out an initial assessment of your application. As a result of this initial assessment
you may be required to provide further information to support your application; (2) The Proposer/Seconder (Supporters) are typically the
Supervising Engineers or Mentors who are professional engineers or corporate members of IEM. Please refer to the Guidance Notes on PI
Application on the definition of Proposer/Seconder (Supporters).

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 IEM PI A100
Professional Interview Application Form
Jan 2017

I Declaration

I declare that I do not plagiarise in this application. I understand and consent to the information provided on this form being
processed by the IEM for its sole use and that of its associated organisations, including the Board of Engineers, Malaysia
(BEM) for professional interview purpose. I declare that the statements made on this form are to the best of my knowledge
true, and agree that the validity of my election shall depend upon the accuracy of the particulars contained herein. I
acknowledge that in the event my qualifications are found to be non-compliant to the admission criteria of the Institution due to
changes in policies or oversight at the time of admission, the Institution reserves the right to withdraw my membership. In the
event of my election, I agree to comply with the Constitution, By-Laws and Regulations of the Institution for the time being in
force, and understand that this is a commitment to behave ethically within my profession; please refer to IEM Website.

Signature of Candidate Date

J Proposer & Seconder (Supporters) Details

I, the undersigned, support the candidate from professional knowledge as worthy of consideration for the Professional
Interview and I endorse the content of this application.
Proposer (Supporter 1) (mandatory)
Name Signature Date
(print) (sign)
Address for communication

Postcode Phone Email

Professional Registration (if applicable) e.g. PEng, CEng Membership of Engineering Institutions e.g. MIEM, FIEM

Membership Number (if applicable)

Seconder (Supporter 2) (mandatory)

Name Signature Date
(print) (sign)
Address for communication

Postcode Phone Email

Professional Registration (if applicable) e.g. PEng, CEng Membership of Engineering Institutions e.g. MIEM, FIEM

Membership Number (if applicable)

Seconder (Supporter 3) (optional)

Name Signature Date
(print) (sign)
Address for communication

Postcode Phone Email

Professional Registration (if applicable) e.g. PEng, CEng Membership of Engineering Institutions e.g. MIEM, FIEM

Membership Number (if applicable)

Notes for Proposer &Seconder (Supporter(s) - Before signing the application form, you are requested to ensure that the presentation of the
form is to the candidate’s best advantage and provides adequate information to enable the IEM to reach a decision. Please note you will be
required to complete an Inquiry Form on the candidate’s eligibility for professional interview.

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 IEM PI A100
Professional Interview Application Form
Jan 2017

Checklist
Have you: Yes/No

1. Read the guidance notes on how to complete your application.

2. Completed all sections of the form clearly in BLACK ink and on white paper only (colour and
grey become unreadable when copied and should not be used).

3. Enclosed a copy of your registration with the Board of Engineers, Malaysia (BEM), signed by
one of your Proposer & Seconder (Supporters) as a certified true copy of the original.

4. Enclosed a copy of your Engineering Degree and any engineering qualification certificate(s),
as well as the academic Degree transcripts signed by one of your Supporters as a certified
true copy of the original.

5. Clearly marked your position on the Accountability Diagram in Section I, and put the dates you
held that position.

6. Initial on every page of the Application Form; and signed the Declaration.

7. Enclosed the Training and Experience Report with the requirements as detailed in the relevant
guidance notes.

8. Checked that your Proposer & Seconder (Supporters) comply with the requirements as
detailed in the guidance notes.

9. Enclosed the Technical Report based on the requirements as detailed in the relevant
guidance notes.

10. Obtained the signature of your Supervisor / Supporter to endorse career history, accountability
diagram, and professional development in this form.

11. Enclosed the appropriate application fee which is payable to the Institution of Engineers,
Malaysia (IEM).

12. Read the IEM Constitution, By-Laws and Regulations on Professional Conduct.

13. Retained a copy of your application.

Please send your completed form and payment to:

Bangunan Ingenieur, Lots 60/62, Jalan 52/4,

Peti Surat 223 (Jalan Sultan),
46720 Petaling Jaya,
Selangor Darul Ehsan,
Malaysia

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