PHILIPPINE INSTITUTE OF INDUSTRIAL ENGINEERS Please

G/F Pacific Coast Plaza, Coastal Road, Parañaque City 1701 Affix
Tel. No. (632) 879-8381 Telefax no. (632) 879-8103 Email: piie@pldtdsl.net Latest
Website: http://www.piie.org 1" x 1" photo

MEMBERSHIP APPLICATION

Name: Mr. / Ms.

Last First Middle Initial
Date of Birth: Nickname:
Home Address:
Preferred Mailing Address for PIIE Correspondence (check one) Home Work
Title / Department / Position:
Employer:
Address:
City / State / Province:
Phone Number: Home: Office: Fax:
E-mail Address: Cellphone No.:
For Institutional Membership (Allowed to have one Alternate member)
Name of Alternate Representative:
Position: E-mail Address:
Address:
Phone Nos.: Fax No.:
Requirements:
1. Resume of Applicant / Representative 2. Annual Membership Fees
1. Type of Membership (Please check applicable status) Amount
Individual / Industry [ ] P1,500.00
Academe [ ] P1,000.00
Student Chapter [ ] P1,500.00
Institution [ ] P3,500.00
P1,200.00 - individual member rate for those whose institution is a member
P0,750.00 - individual member rate / professor whose institution is a member
P0,500.00 - individual member rate / student within one year after graduation
Mode: Cash Check Bank Name: Check # Amount O.R. #

Preferred Committee:
[ ] Programs (GMMs) [ ] Promotion
[ ] Membership (Industry / Academe) [ ] Certification / Technical
[ ] Student Chapter [ ] Ways and Means
[ ] Publications [ ] National Congress
[ ] Amendements [ ] Fellowship
[ ] Professional Development
Signature of Applicant / Representative PIIE Membership Chairman