Philippine Society of Mechanical Engineers INTEGRATED ASSOCIATION OF MECHANICAL ENGINEERS PSME NATIONAL HEADQUARTERS 19-A Scout Bayoran St., Bgy South Triangle Quezon City, Philippines Tel: (632) 7752-25-27 Mob. No. 09178681700 Email: national@psme.org.ph Website: www.psme.org.ph APPLICATION FOR MEMBERSHIP I hereby apply for admission to the SOCIET Y as THREE REFERENCES (PSME Regular / Life Members): (Please SHADE the appropriate box) 1. Name : Student Member Address: Associate Member (BSME Graduate or CPM) Regular Member 2. Name Life Member Address: CHAPT ER: 3. Name Address: PSME Identification Number: Personal Information LAST NAME: Gender: T el No: FIRST NAME: Birth Date: Mobile No: MIDDLE NAME: Citizenship: Email Add: Complete Home Address (include ZIP code): Place of Birth: T AX Identification No: Marital Status: SSS / GSIS Name of Spouse: Number of Children: Collegiate Attainment Name and Address of Academic Institution T ype of Degree: Date Conferred: Professional Credentials PRC Professional Grade License Number Date Registered Professional Mechanical Engineer (PME) Registered Mechanical Engineer (ME) Certified Plant Mechanic (CPM) None (BSME Graduate) Others (Please specify) Area of Professional Practice / Technical Division Group Fire Protection Boiler, Pressure Vessel & Piping Automation, Robotics & Instrumentation Power & Energy Manufacturing Engineering Mechanical Ventilation & Air Conditioning-Refrigeration Project Management Environmental Engineering Plant Engineering & Maintenance Energy Management Safety Engineering & Health Retired Automotive Engineering Mechl. Design & Fabrication Others (Please Specify): _____________________________________ Employment History Employer / Company Name & Complete Address, Tel. Nos. Employment Date Position / T itle / Designation From Current Company as A lternate Mailing A ddress: YES To NO (Append extra sheet if necessary) certification I subscribe to the foregoing information and if elected as member, I will be governed by the Constitution and By-laws of the Society and its Code of Ethics. Futhermore, I agree to promote the objectives of the Society and to participate in the programs and activities of PSME. Passport size Photo Signature Date Note: All information given by the member are strictly confedential in support and compliance with the Data privacy act. Membership Fees Life Entrance None Annual Dues None One Time Regular Associate Student None None None Official Receipt Date Issued WRITE YOUR FULL NAME HERE: PSME-ADM-FM-030 FEBRUARY 1, 2020