PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC

Unit 703, 7/F Future Point Plaza 1 Condominium, 112 Panay Avenue, South Triangle, Quezon City
Telephone Nos: +63 2 837 65028 / 839 81434
Cell No. +63 927 043 2553 (Globe)
Email: membership@pice.org.ph / picenational@pice.org.ph / Website: www.pice.org.ph

STUDENT MEMBERSHIP REGISTRATION FORM

DATE OCTOBER 21, 2023

PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC. PANGASINAN-

STUDENT CHAPTER
PHINMA UNIVERSITY OF PANGASINAN STUDENT CHAPTER

MOTHER CHAPTER PHILIPPINE INSTITUTE OF CIVIL ENGINEERS PANGASINAN CHAPTER

ENROLLED IN YEAR 2023-2024

COLLEGIATE YEAR

LAST NAME FIRST NAME MIDDLE NAME SUFFIX

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:
PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC. PANGASINAN-
Endorsed By: (School Chapter) PHINMA UNIVERSITY OF PANGASINAN STUDENT CHAPTER

Student Chapter Adviser: ENGR. CHERRYPIE S. PACIS & ENGR. RENZIE KEANE A. DUMAGUING

Student Chapter President: ROMEL ADRIAN G. ROMERO

Date Submitted: OCTOBER 21, 2023 Membership No:

(Year-Charter No. – Membership No.)

PRIVACY NOTICE: Your responses and personal information will be kept confidential. Other than personal information you voluntarily provide in
response to this application, we will not collect any other personal information pertaining to you. Your responses will be accessed only by the
relevant personnel in the PICE Secretariat, or their authorized representatives, and will not be shared, distributed or disclosed to any other third
person. When this information is no longer required for this purpose, secure procedures will be followed to dispose of your data. If you have any
concerns about the processing of your data, you may contact the Data Protection Officer at dataprotection@pice.org.ph

As of 3 May 2023