7/13/2014 Membership Application Form

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INDIAN INSTITUTE OF CHEMICAL ENGINEERS
Dr.H.L.Roy Buliding, Jaduvpur university Campus.
Raja Subhod Chandra Mullick Road
Kolkata-700032
Email-id:- iichehq@vsnl.com
Telephone :-033-24129314/24129314
Membership Application Form
Catagory of Membership applied for
Member:
Life Member:-
Associate Member:-
Life Associate Member:-
Transfer of Membership catagory:- SM---->AM AM---->M
1. NAME (IN BLOCK LETTERS)
Last,First,Middle
[Last]
[First]
[Middle]
2. Designation :-
3. Address [official] 4. Address [Residential]
Pincode :-

Pincode :-

Phone-Office:-
Phone-Residence:-

Mobile :-
Email-Office:- Email-residence:-
5. Address for Communication:-
Office:-
Residence:-
6. Date of Birth :-
(dd/mm/yyyy)
/ /
7. Sex:- Male Female 8. Nationality:-
9. EDUCATIONAL QUALIFICATIONS :-
(Copy of degree(s)/ diploma(s) must be attached if you are not already a Member of IIChE or if you have obtained additional
qualifications after becomeing a corporate member.)
Degree/Diploma Year College/University Major Field Code
7/13/2014 Membership Application Form
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Degree Code: Chem. Engg: 01, Chem. Tech: 02, Allied Process Tech.: 03, Other Engg: 04, Science: 05 Diploma Code: AMIIChE:
06, AMIE: 07, Dip. Chem. Engg. / Tech.: 08, Others (Specify):09.
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10. PROFESSIONAL EXPERIENCE: (Attach separate sheets if necessary)
Employee (Current) Employee (Previous)
Address:- Address:-
Position :-
From: To:
Position :-
From: To:
Nature of duties and responsibilities related to Chemical Engineering:
11. SPECIALISATION:-
12. In case you were a student member / associate member, Membership Number: SM/AM
Year: From: To:
13. SUPPORTERS (One must be a corporate member of IIChE, the other may be employer.
Name:- Name:-
Address:- Address:-
Membership Number:- Membership Number:-
Signature: Signature:
Seal: Seal:
14. PAYMENT DETAIALS:-
Payment should be made by at per Multicity Cheque / Demand Draft(DD) in favour of
INDIAN INSTITUTE OF CHEMICAL ENGINEERS payable at Kolkata
Registration Fee Rs:- Admission/Transfer Fee Rs:-
Annual Subscription/Compouding Fee Total Payment enclose
7/13/2014 Membership Application Form
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Rs:- Rs:-
Demand Draft/Cheque on (Bank) :
No: Dated :
15.DECLARATION BY THE APPLICANT:
I, the undersigned, attest that the particulars given above by me are true. If elected to Membership, I agree to abide by the
Constitution and the bye-laws of the Indian Institute of Chemical Engineers.
Place:-
Date:-
Signature of the Applicant
FOR OFFICE USE ONLY
Application Receive No:-
- -
Acknowledged on:-
- -
Registration No:-

To Register/Secretry:
- -
From Register/Secretry:
- -
To Council:
- -
AdviceSent No:
- -
Formalities Completed No:- - -
Council's Decision
Elected / Not elected
Membership Number Allotted:

Receipt Number:

Despatched on:
- -
Despatched on: - -
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Fees & Subscription Details
Registration Fees for all the categories Rs:- 100/-
Members Catagories Admission Fee(RS) Annual Subscription Fee(RS)
Member 350 350
Associate Member
(-age 35 years and above)
350 350
Associate Member
(-age below 35 years)
250 250
LIFE MEMBERS
Age (in years) as on 31st March Next Compounding Fees(RS)
26-50 4,000/-
51-60 3,000/-
61 and above 2,000/-
LIFE ASSOCIATE MEMBERS
Age (in years) as on 31st March Next Compounding Fees(RS)
7/13/2014 Membership Application Form
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All age groups 3,000/-
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