TTHE INSTITUTION OF ENGINEERS (INDIA) https://www.ieindia.info/Fellowprint.

aspx

Tel No.(91)(033)2223-8311/14/15/16/33/34,Fax No.(91)(033)2223-8345,E-mail:membership@ieindia.org

*SURNAME: MOHAMMED BASHEER

*REMAINING NAME: SHAMNADH
SON/DAUGHTER/WIFE OF: A MOHAMMED BASHEER
GENDER: Male
HOME: NISHAD MANZIL
STREET: NEAR MEERASAHIB HALL, PALLIPURA,M P O
CITY: THIRUVANANTHAPURAM
COUNTRY: INDIA
STATE: KERELA
TEL(O):
TEL(R): 04712756534
PIN: 695316
MOBILE: 9447968166
EMAIL: shamnadhm@gmail.com
DATE OF BIRTH: 27/9/1976
AGE AS ON DATE: 34 YEARS 6 MONTHS 20 DAYS
NATIONALITY: INDIAN
EXISTING GRADE
AND MEMBERSHIP NO.:
AMOUNT.: 3100
REFERENCE NO.: 110203364190

The Secretary of Director General

The Institution of Engineers(India)
8 Gokhale Road,Kolkata 700020 Date................

Dear Sir,

1. I hereby apply for election as a Member of the Institution of Engineers(India) in accordance with the Charter of Incorporation and the
Bye-Laws as they may be legaly altered hereafter.
2. I do hereby undertake that in the event of my election as a Member,I will be governed by the Bye-Laws and the Regulations of the
Institution as they now are or as they may hereafter be legally altered and that I will accept as final and binding the decisions of the
Council in all matters dealt with by them in accordance with the provisions of the Charter,Bye-Laws and Regulations, and will
forthwith cease to describe myself as a Member or to designate myself as belonging to the Institution in any other form, on receipt of
a notice from the Secretary and Director General that acting under the powers conferred upon them by the Bye-Laws and Regulations
the Council have declared me to be no longer as a Member of the Institution.I further undertake that I will promote the objects of the
Institution,as per as may be in my power,provided that whenever I shall signify in writing to the Secretary and Director General that I
am desirous of withdrawing from the Institution,I shall after the payment of any arrears which may be due by me at that period be
free from this obligation.
3. I have noted that the decision of the Council of the Institution shall be final in granting the Membership and the District courts at
Alipore, 24 parganas(South) shall have the exclusive jurisdiction in setting the dispute,if any,arising out of this Membership.
4. I accept responsibility for the accuracy of the particulars contained in the application form with regard to my qualification and

1 of 6 3/17/2011 11:48 AM
TTHE INSTITUTION OF ENGINEERS (INDIA) https://www.ieindia.info/Fellowprint.aspx

experience and agree that if I am elected the validity of my election shall depend upon the accuracy of such particulars as required in
the Bye-laws.I also undertake to abide by professional conduct rules and/or code of ethics that the Council may frame from time to
time.

Yours faithfully

Encl. Copies of .......................documents. ........................................

Signature of the applicant(*in English only)

..............................................................................
Regn. No.
Signature 110203364190
------->
*Attested

*In case of regional language,signature, Do not write anything within the box
attestation is a must by a Gazetted Officer with Seel (for office use only)

SUPPORTERS : From personal knowledge of the applicant and in consideration of his/her qualifications as stated on the reverse.I
recommended him/her to the Council as being in every way a fit and proper person to be admitted to the Institution as a Member.

Name (in Capitals) Membership No. Signature (in English only) with date

F................................................. .................................................
1. ..................................................
F/M/AM...................................... .................................................
2. ..................................................

All attached documents are to be attested by the supporters only

2 of 6 3/17/2011 11:48 AM
TTHE INSTITUTION OF ENGINEERS (INDIA) https://www.ieindia.info/Fellowprint.aspx

*Note: The applicant of Group of Engineering/Technology shall be attached to the respective Engineering Division as per table
given bellow.For Instrumentation & Measurement,Instrumentation Group,option may be excercised and indicated.

Group of Engineering/Technology Engineering Division

Petroleum,Petrochemical,Biotechnology,Food Technology,
Biochemiacal Engineering,Pulp and Paper Technology,
Sugar Technology,Leather Technology,Plastics & Rubber Chemical Engineering
Technology,Polymer Engineering,Oil Technology,Paint
Technology
Ceramics Metallurgy & Materials Science
Information Technology Computer Engineering
Electronics & Telecommunication Engineering/Electrical
Instrumentation Measurement,Instrumentation
Engineering
Industrial Engineering Production Engineering
Power Engineering Electrical Engineering
Automobile Engineering Mechanical Engineering

* Please indicate choice of attachment to Division where applicable,(indicate one Division only).Please see 'Note'.

MECHANICAL

Please select if you wish to receive on payment ONE or TWO Division part(s) of the Journal

JOURNAL YEAR

3 of 6 3/17/2011 11:48 AM
TTHE INSTITUTION OF ENGINEERS (INDIA) https://www.ieindia.info/Fellowprint.aspx

Note: Each information provided by the applicant must be authenticated by a supporter of the application
Name of Full Name and Address of
Branch Year
Examination/sPassed ExaminingAuthority theCollege/Institution IE(I)Roll
ofEngineering ofPassing
or Section'B' of IEI No.......
SCT COLLEGE OF
MECHANICAL UNIVERSITY OF ENGINEERING ,
B.TECH 1999
ENGINEERING KERALA PAPPANAMCODE,
THIRUVANANTHAPURAM-18
TKM COLLEGE OF
UNIVERSITY OF
M.TECH MECHANICAL ENGINEERING , KARIKODE , 2008
KERALA
KOLLAM-5

Present position:-
Exact Designation Place of Posting Full name and address of the present employer
ASSISTANT KOLLAM, PRINCIPAL, TKM COLLEGE OF ENGINEERING, KARICODE ,
PROFESSOR KERALA KOLLAM-5
In the case of Self-employment/consultant:Please enclose(i)Profile of the Organization,(ii)Value of works(Yearwise, in money
worth)and (iii)Nature of Projects handled duly attested by a supporter.Uptodate Chronological Engineering Career
Designation(S)of
Name and address of Employer From(Date) To(Date)
posts(s)held
PRINCIPAL , YOUNUS COLLEGE OF ENGINEERING
LECTURER 16/10/2002 21/10/2009
KOLLAM-10
ASSISTANT PROFESSOR PRINCIPAL TKM COLLEGE OF ENGINEERING, KARICODE ,
21/10/2009
KOLLAM-5

4 of 6 3/17/2011 11:48 AM
TTHE INSTITUTION OF ENGINEERS (INDIA) https://www.ieindia.info/Fellowprint.aspx

For Military Personnel only

(i)Present Rank
(ii)Actual date of Commission,and
(iii)Personal Number
Details of Professional Career:
(a)Most Important Engineering works for which Personally Responsible(Please attach statement duly attested)
(b)Research and Teaching Experience(if any)
(c)Specialisation(if any)[Please attach sheet duly attested]
Technical Papers Published(if any)
Title of the Paper Name of Journalin which Published Date of Publication

Membership of other Engineering Institutions/Societies(if any)

Name of Institution/Society Grade ofMembership Date ofElection Whether Stilla Member
ISTE LIFE MEMBER YES

5 of 6 3/17/2011 11:48 AM
TTHE INSTITUTION OF ENGINEERS (INDIA) https://www.ieindia.info/Fellowprint.aspx

Please make sure that you print the additional page bearing space for specimen signature and photograph of applicant.
The additional page must be submitted with a hard copy of this form. Click Here

PRINT>>

PLEASE PRESS PRINT/SAVE BEFORE GOING TO PAYMENT GATEWAY

CLICK HERE FOR PAYMENT GATEWAY

6 of 6 3/17/2011 11:48 AM