INDIAN INSTITUTION OF INDUSTRIAL ENGINEERING

National Head Quarters, IIIE Bhavan, Sector -15, Plot No. 103,
CBD Belapur, Navi Mumbai - 400 614
Tel : 022-7562562/ 757 9412 Telefax : 7579412
APPLICATION FORM FOR ADMISSION
IMPORTANT: The application must be proposed and Seconded by a Current Corporate
Member who should verify as many as they my be able to, Statements in respect of Qualification and their
Signed Endorsement VERIFIED Should be placed against the respective entries.
Please read very carefully the relevant portion of the Rules before filling the portion and sent the application to Executive Secretary, at above given address.

1. Class of Membership Applied (Put X in relevant Box)

CORPORATE STATUS
MEMBER

NON-CORPORATE STATUS

ASSOCIATE MEMBER

AFFILIATE MEMBER

2. Full Name (In block letters)

ASSOCIATE

3. Date of Birth
(Please enclose copy of SSC Certificate)

First
4a. Present Address

Middle

Last
4b. Permanent Mailing Address

Office :
Phone :
Residence :
Phone :

Phone :

SPACE BELOW THIS LINE FOR OFFICE USE ONLY - PLEASE TURN OVER FOR FILLING ITEMS 5 TO 13

General Academic Qualification

Professional Qualification

Training

Non Industrial Eng. Experience Industrial Eng. Experience

Present Qualification

Application
Received

DATE

INITIALS

IIIE Examination

Position

Submitted
to Membership
Committe

Amount
Received

Since when

Receipt No.
and Date

Receipt Sent
On

Admission
Letter Sent

Certificate
Sent on

Particulars mentioned in Items 5 to 10 should supported by attested copies. Attestation is

necessary for Xerox copies also.
5. Academic Qualification - Details after Matriculation/ SSC (please endorse copies of Degrees/ Diplomas)
Degree
Diploma

Name of the Institution

University

Special Subjects

Year of
Passing

6. Training Courses Attended - Duration one week or more (Please specify if courses undertaken are part time
Principal Subjects of Course

Counducted by

Special
Subjects

Year of
Passing

7. Publication
Published by

Title of article, paper, books etc

Month/ Year

8. Membership of Academic and Professional Institutions

Name of the Institution

Class of
Membership

Membership
Number

Year from

JOB HISTORY
9. Experience in Business, Industry, Institution etc.
Name of the Organisation and designation of
Position (latest Position First)

Brief Description of Duties and

responsibilities (attach additional sheet
if required)

Period
To

From

10. Work Experience ( Please enclose employers Certificate in support of position held and responsibilities carried out)

in Industrial Engineering Field

Name of the Organisation & Designation

Relevant details of duties and responsibilities

Period
From

To

Particulars of present position other than in Industrial Engineering

Kindly attach additional sheet if space is insufficient.

Designation & Since when

Nature of Duties and responsibilities No. of employees directly reporting to you

Industrial Engineer :
Supervisory
:
Non Supervisory
:
Total No. of employees
in organisation
:

Name & Designation of

Immediate Superior

Name, Address & main activities of

employer

Salary Bracket
Below
Rs.5000
Over Rs.5000 & Below 10000
Over Rs.
Rs. 10000

11. Expertise acquired in Industrial Engineering Techniques

Any significants points, achievements, etc. you would like to mention

Kindly attach additional sheet if space is insufficient

12 Fees
A crossed bank draft No. ______________________ dated ____________ for Rs. ____________________
(in words)_____________________________________________________________________________ (These
should be in favour of Indian Institution of Industrial Engineering & Payable at Mumbai) towards
Registration Fee/ Subscription.
13 Undertaking
I, the undersigned, certify the above statements to be correct and hereby agree that in the event of
my being elected to any class of membership and so long as i continue to hold that membership. I will
be bound by and observe the provisions of the constitution and bye-laws of the Indian Institution of
Industrial Engineering as they exist now or as they may hereafter be modified from time to time and
that I will endeavour to further the objectives of the Institution.

Date :

Applicants Signature

14 Statements of Proposer & Seconder

The Proposer and the Seconder must be a Current Corporate Member of the IIIE and are required to verify as
many as they may be abe to the statements of the applicant in respect of his qualification and experience.
PROPOSER

SECONDER

Having known the applicant personally for _______

years. I recommend that the applicant may be
considered for admission as _____________________
Member.

Having known the applicant personally for _______

years. I recommend that the applicant may be
considered for admission as _____________________
Member.

Name of Proposed :
(In block letters)

Name of Proposed :
(In block letters)

Membership No.
Signature:

Date :

Membership No.
Signature:

Date :