The Institution of Engineers ( India) PSC

8 GOKHALE ROAD, KOLKATA - 700 020

MEMBERSHIP NO.

Polytechnic Abbreviated Form of the Membership

PIN Code Number Polytechnic Name Serial Number
(Above portion to be filled in by the Adviser of the Chapter)

Name :

Father,s Name/Husband’s Name :

Address for Communication :

E-mail ID : Mobile No. :

Date of Birth : D D M M Y Y Y Y

Name of the Institution/ Branch of Engineering Year of Study Fees Paid (`)
Polytechnic College

I hereby apply for enrolment as a member of Students’ Chapter of The Institution of Engineers(India) in accordance with the rules of the Chapter and
the Bye-laws and Regulations as they now stand or hereinafter be legally altered. I do hereby undertake that I will be governed by the Bye-laws and
Regulations of the Institution. I accept the responsibility for the accuracy of the particulars contained in the above and I agree that, if I am enrolled, the
validity of the enrolment shall depend upon the accuracy of the particulars as required under the Bye-laws. I also undertake to abide by the conduct of
rules and / or Code of Ethics that the Council may prescribe from time to time

Signature of the Applicant (in English only)

I certify the application and information featured above for consideration to induct the applicant in IEI fold as an PSC Member of IEI

(Signature of the Adviser of the Polytechnic Students’ Chapter with seal and date)

 This portion to be retained by the Chapter   This portion to be retained by the Student 

The Institution of Engineers ( India) The Institution of Engineers ( India)

(Established 1920, Incorporated by Royal Charter 1935) (Established 1920, Incorporated by Royal Charter 1935)
8 Gokhale Road, Kolkata 700 020 8 Gokhale Road, Kolkata 700 020

MEMBERSHIP NO. MEMBERSHIP NO.

Polytechnic Abbreviated Form of the Membership Polytechnic Abbreviated Form of the Membership
PIN Code Number Polytechnic Name Serial Number PIN Code Number Polytechnic Name Serial Number
(Above portion to be filled in by the Adviser of the Chapter)
(Above portion to be filled in by the Adviser of the Chapter)
This portion to be retained by the Student

Name : ....................................................................................................................................
Name :
Branch : ..................................................................................................................................
First/Second/Thrid (Tick here) Photo Name of the Institution :
Roll No. : .................................................................................................................................
Vaild upto :

Signature of the Student Signature of Adviser with seal Signature of the Student Signature of Adviser with seal