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FORM A
REGISTRATION OF ENGINEERS ACT 1967
REGISTRATION OF ENGINEERS REGULATIONS 1990
(Regulation 16)
APPLICATION FOR REGISTRATION AS A GRADUATE ENGINEER
PERSONAL DETAILS
Reference No. : JS 129500
Name : MUHAMMAD 'IZZAD AFIF BIN NORDINTitle :
Gender :
Date of Birth :
Place of Birth :
Citizenship :
New IC No : 901222105157
Old IC No :
Address :
Postcode / City :
State :
Country :
Tel No. :Mobile No :
Fax No :
Email (1st) : [email protected]
Email (2nd) :
Academic Qualification :
Professional Quali fications/Training (if any) :
ACADEMIC QUALIFICATIONS
Name of Certificate/Diploma/Matriculation/ A Level :
Name of Institute/College :
Year of Study : ToName of Degree :
Engineering Course :
University :
Campus :
Country :
Period of Study : years
Year of Study : to
Mode of Study :
Other Qualification (if any) :
University/College Degree Course Country Year Intake Year
Award
-- no record --
Engineering Disciplines :
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DECLARATION TO BE SIGNED BY THE APPLICANT
The Registrar,Board of Engineers Malaysia
I, the undersigned, apply for registration as a Graduate
Engineer and declare as follows:
I am a Malaysian citizen.
I am a Permanent Resident of Malaysia.
I am not a bankrupt.
The particulars given in this form and the certificates attached
are true and correct.
I agree to abide by the Registration of Engineers Regulations
1990, including the Code of Professional Conduct
Date
.............................................................
.............................................................(Signature
of Applicant)
Section 24(a) of the Registration of Engineers Act 1967: "Any
person, sole proprietorship, partnership or body corporate who
procures or attempts toprocure registration or a certificate of
registration under this Act by knowingly making or producing or
causing to be made or produced any false orfraudulent declaration,
certificate, application or representation whether in writing or
otherwise, shall be guilty of an offence and shall, on conviction,
beliable to a fine not exceeding ten thousand ringgit in the case
of an individual, or fifty thousand ringgit in the case of a sole
proprietorship, partnership orbody corporate, or to imprisonment
for a term not exceeding three years, or to both.".
