FORM A2

PERTUBUHAN JURUUKUR MALAYSIA
The Institution of Surveyors, Malaysia
3rd Floor, Bangunan Juruukur, 64-66, Jalan 52/4, 46200 Petaling Jaya, Selangor
Tel: 03 - 79551773/79569728/79548358
Fax: 03-7955 0253
Website : www.ism.org.my
Email: secretariat@ism.org.my

APPLICATION FOR ELECTION AS A MEMBER
Divisions:
Geomatic & Land Surveying / Quantity Surveying / Property Consultancy & Valuation Surveying / Building Surveying

Full Name

: __________________________________________________

Other Names

: ________________________________ Gender: ___________

Date & Place of Birth
Nationality Status

: __________________________________________________

M

Please affix your photograph
here. An additional
photograph is to be enclosed
with this application

: __________________________________________________

Identity Card New

: ________________________________ Old : ___________

Passport No

FOR OFFICE USE ONLY

: ______________________________

Regular Business Address

: __________________________________________________

_____________________________________________________________________

Date Received

:

Date Referred To
:
Divisional Committee
Date

:

Office No

: ____________________________ Postcode : ______________________

Mobile No

: ____________________________ Fax No : ______________________

Date of Admission

:

Date Of Notification

:

: __________________________________________________________

Membership No

:

Email

House Address

Recommended

Signature of Secretary :

: ______________________________________________________

_____________________________________________________________________
_

Tel No :

To:

______________________

Date:

Secretary General
The Institution of Surveyors Malaysia

I, ________________________________________________________________________
(NAME IN BLOCK LETTERS)
hereby apply to be a Member of The Institution of Surveyors Malaysia and declare as follow:
A.

QUALIFICATION
1.

ACADEMIC QUALIFICATION

a)

Degree : _______________________________________________________________________________________________

b)

University / College / Institute: _____________________________________________________________________________

c)

Year of Graduation : _____________________________________________________________________________________

d)

Diploma : ______________________________________________________________________________________________

e)

University / College / Institute: _____________________________________________________________________________

f)

Year of Graduation : _____________________________________________________________________________________

1

etc. ________________________________________________________________________________________________ Name of Employer in BLOCK LETTERS: _______________________________________________________________ 2 . EMPLOYMENT DECLARATION The declaration on this page must be signed by the Principal or Partner in the candidate’s firm. the signature of the head. or his / her authorized deputy. Other Professional Qualifications: ____________________________________________________________________________ ii. Practical Experiences: ____________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ b) Year of Passing ISM Professional Examination (Final / Direct Final) : _________________________________________________ OR c) Any Other Equivalent Examination: ____________________________________________________________________________ ________________________________________________________________________________________________________ B. a) The candidate is employed in the capacity of: ___________________________________________________________ ________________________________________________________________________________________________ b) The candidate is engaged on the following duties: ________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ c) Name and qualifications of the person directly responsible for the candidates’ training ________________________________________________________________________________________________ d) Signature of Principal or Head of Department with qualifications. degrees.2. PROFESSIONAL QUALIFICATIONS AND TRAINING a) i. of the technical department in which the candidate is engaged must be obtained. Where the candidate is employed in the public service in a branch office of by a large undertaking.

propose and recommended him / her as a fit and proper person to be admitted as a full member of The Institution.C. testimonials. the undersigned being Fellow / Member of ISM do. PROPOSER AND SECONDERS We. PROPOSER SECONDER SECONDER Name (in block letters) Address: Signature Date: NOTE: D. certificates and other relevant documents in support of the application must be submitted * Delete where appropriate 3 . Signature : Date : ___________________________________________ Note : Certified photostate copies of IC. from our personal knowledge of the above applicant. APPLICANT’S DECLARATION I hereby certify that the above particulars are correct. Signature of the members of ISM (of whom one must be Fellow)OR of two members of the Council whom the President must be one.

Sign up to vote on this title
UsefulNot useful