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FORMULIR APLIKASI

ASEAN CHARTERED PROFESSIONAL ENGINEER

INDONESIA MONITORING COMMITTEE
2015

 Mining Eng.: E-mail: Identity Card No.  Petroleum Eng. : for the amount of Rp.: Date of Birth: First Degree / University: Discipline of Engineering: Graduate Engineer Registration No. Date of previous application: (Write NIL if not applicable) Date: ( ) *delete whichever is not applicable (signature) rev 03 Page 1 of 3 . No.  Environmental Eng.  Electrical Eng. APP 01 APPLICATION FOR A PROFESSIONAL ENGINEER TO BE REGISTERED AS ASEAN CHARTERED PROFESSIONAL ENGINEER (ACPE) (To be completed by Applicant in BLOCK LETTERS with BLUE INK) Name: Name to be put in the certificate: Address: Tel .  Civil Eng.  Chemical Eng.: Date of Registration: Branch of Engineering: Discipline for ACPE Registration (select 1 discipline only):  Mechanical Eng.  Physics Eng.  Structural  Geotechnical  Water  Transportation Resources I enclose herewith * money order / bank draft / cheque no.  Aeronautical Eng. No.: Date of Registration: Professional Engineer Registration No.  Marine Tech  Industrial Eng. being the fee.: Fax.

APP 02 PORTOFOLIO FOR THE APPLICATION AS ASEAN CHARTERED PROFESSIONAL ENGINEER Name: PROFESSIONAL EXPERI ENCE IN RESPONSIBLE CHARGE OF SIGNIFICANT ENGINEERING WORK A B C EXPERIENCE AREA (in months) E Total D1 D2 D3 D4 D5 Signature of any graduates / study / professional engineers research / teaching Masters / post Date (month State concisely title of position held. who has personal worksOther engineering & year) knowledge of applicants managementPlanning / location and description of each work (make statement position and relating to brief and concise. Position: Name of employer: Client: Project title: Location: Project description: Job description & responsibilities: rev 04 Page 2 of 3 . designating each work upon which address of training or experience in officeDesign / each the period mentioned Site / field engaged with or change of position separately: include professional appointment some indication of magnitude and complexity of work in engineer which engaged. Name. your duties and degree of responsibility) under whom Example: April served & 87 to January 97 (if necessary additional sheets may be attached) contact no. name of employer.

your duties and degree of responsibility) under whom Example: April served & 87 to January 97 (if necessary additional sheets may be attached) contact no. Name. Total (If necessary insert additional rows above) Months rev 04 Page 3 of 3 . APP 02 PROFESSIONAL EXPERI ENCE IN RESPONSIBLE CHARGE OF SIGNIFICANT ENGINEERING WORK A B C EXPERIENCE AREA (in months) E Total D1 D2 D3 D4 D5 Signature of any graduates / study / professional engineers research / teaching Masters / post Date (month State concisely title of position held. name of employer. who has personal worksOther engineering & year) knowledge of applicants managementPlanning / location and description of each work (make statement position and relating to brief and concise. designating each work upon which address of training or experience in officeDesign / each the period mentioned Site / field engaged with or change of position separately: include professional appointment some indication of magnitude and complexity of work in engineer which engaged.

APP 03 DECLARATION FOR THE APPLICATION AS ASEAN CHARTERED PROFESSIONAL ENGINEER I hereby declare that: I have had years of practical experience in engineering. YES NO I am a Professional Engineer I meet the entire requirement as stated in Article 3 of the ASEAN Mutual Recognition Arrangement (MRA) No disciplinary action have been taken against me I am not a bankrupt Others: I declare that I have not submitted any other application to the Monitoring Committees of any other ASEAN Member State for registration as ACPE.: Date: Note: Please tick (√) in the relevant box. rev 03 Page 4 of 3 . (signature) Name: PE Reg. No. Yours Sincerely.