INDIAN INSTITUTE OF CHEMICAL ENGINEERS

Dr H. L. Roy Building, Jaduvpur University Campus
 Raja Subodh Chandra Mullick Road
 KOLKATA - 700 032
 Telephone: 033-24146670/24129314                         Email: iichehq@vsnl.com

APPLICATION FORM FOR FELLOWSHIP

(Fellow Membership is awarded on the professional achievements in the field of Chemical Engineering. Seven copies of the application with necessary enclosures are to be submitted.)

Indicate the category of IIChE Corporate Membership of the applicant.

Member [M], Associate Member [AM], Non-Member [NM]

Membership Number:

1. NAME (IN BLOCK LETTERS)
             Last, First, Middle:

--

2. Employer:

Designation:

3. Address - Offical

4. Address - Residential

Phone - Office: 

Mobile:

Phone - Residence: Mobile:

E Mail - Office:

E Mail - Residence:

5. Address for Communication:                                                     Office                                             Residence

6. Date of Birth (dd.mm.year):

7. Sex: MaleFemale

8. Nationality:

9. EDUCATIONAL QUALIFICATIONS: (Copy of degree(s) / diploma(s) must be attached if you are not already a corporate member of IIChE or if you have obtained additional qualifications after becoming a corporate member.)

Degree / Diploma

Year

College / University

Major Field

Code

Degree Code:   Chem. Engg: 01,   Chem. Tech: 02,    Allied Process Tech.: 03,  Other Engg: 04,   Science: 05
Diploma Code:   AMIIChE: 06,   AMIE: 07,   Dip. Chem. Engg. / Tech.: 08,   Others (Specify): 09.

- 1 -

10. PROFESSIONAL EXPERIENCE: (Attach separate sheets if necessary) 

Employer (Current)

(Previous)

Address:

Position:
From:to:

Position:
From:to:

Nature of duties and responsibilities related to Chemical Engineering:

11. SPECIALISATION:

12. ACCOMPLISHMENTS / ATTAINMENTS:
(Due credit to the members of the team should be given wherever applicable.)

a. Academic / R & D: Number of research projects supervised:

    Masters:,     Doctoral: ,     Sponsored:

b. Number of publications: Books: ,     Papers (Journal): ,     Papers (presented):

c. Number of industrial projects: Prepared: ,    Implemented: ,
    New technology developed: ,                      Implemented: ,
    Consultancy projects: ,                                Inhouse reports:

d. Involvement in Academic Institution / R & D Organisation - Industry Interaction (Adjunct Faculty / Joint Project Supervision / Curriculam Development / Joint Academic Programmes)

e. Number of awards and honours received:

f. Membership: Professional Societies: ,      Academic bodies:,
                Industrial Boards / Associates: , Social Organisations:

g. Involvement in IIChE activities (National / Regional Level) in brief.

   Involvement in other professional bodies:

13. MOST SIGNIFICANT CONTRIBUTIONS MADE IN CHEMICAL ENGINEERING / R & D / INDUSTRY: (Salient points only. Details can be given on a separate sheet.):

14. DETAILED INFORMATION APPENDED ON SEPARATE SHEETS: (regarding items 9 to 13, such as list of projects, books, papers, honours and awards, membership etc.

Item No.

Annexure No.

Page No.

- 2 -

15. SUPPORTERS (One must be a fellow of IIChE, the other may be employer / corporate member of IIChE.

Name:

Name:

Address:

Address:

Membership Number:

Membership Number:

Signature:

Signature:

Seal:

Seal:

16. PAYMENT DETAILS:

Payment should be made by at per Multicity Cheque / Demand Draft(DD) in favour of
INDIAN INSTITUTE OF CHEMICAL ENGINEERS payable at Kolkata

Registration Fee: Rs. ,     Admission Fee: Rs. Annul Subscription: Rs.

     Life Fellowship Compounding Fee:  Rs. ,     Total payment enclosed:  Rs. [Fee details are given at end section of the form]

      Demand Draft / Cheque on (Bank) No. Dated:

17. DECLARATION BY THE APPLICANT:
      I certify that the particulars given above by me are true. If elected to fellowship, I agree to abide by the  

      Constitution and the bye-laws of the Indian Institute of Chemical Engineers.

      Place: 
      Date:

FOR OFFICE USE ONLY

Application received on:

Acknowledged on:

Regn. Number:

To Registrar/Secretary:

From Registrar/Secretary:

To Council:

Advice sent on:

Formalities completed on:

Council's Decision:
Elected / Not elected.

Membership Number allotted:

Receipt Number:

Despatched on:

Diploma despatched on:

- 3 -