The Institution of Engineers ( India)8, Gokhale Road, Kolkata 700 020

EXAMINATION APPLICATION FORM FOR

SUMMER / WINTER 2 0 0 0

NAME (in capital letters)

ADDRESS (in capital letters)

E-mail :

Telephone No.Mobile No.

PIN

MEMBERSHIP GRADE

(T/ST/AM/M/F) MEMBERSHIP NUMBER

Scheme Code

(AN=2, AD=3, B=4)

EngineeringBranch Code

(CH=04, CV=05, .........)

* Write Code No. of subjects in serialorder in which desires to appear

* For example, , refer Rules : Vol. 1 effective from Summer 2005 Examination.

FOR SECTION B CANDIDATES ONLY

(a) Passed Section A / Section A (D) / Section B completely in Summer / Winter

with Roll No.

(b) Secured exemption from Section A / Sections A and B in ___________________ (term/year)

I shall abide by the Rules of the Institution Examinations as printed in Rules (Vol. I) effective from Summer 2005 Examination

and revised thereafter from time to time.

Full Signature of Candidate with Date

Enclo: Demand draft of Rs. ______________ no. ________________ dated ____/____/______/

drawn on __________________________________________________ (Bank) in favour of

‘The Institution of Engineers (India)’, payable at Kolkata.

C V 4 1 3

1. Appeared previously in Summer/Winter with Roll No.

2. I wish to appear from Examination Centre Code No.