INSTITUTE OF ELECTRONICS ENGINEERS OF THE PHILIPPINES,

INC. (IECEP) – QUEZON CITY CHAPTER

th
4 Floor NTC Building, BIR Road, East Triangle, Diliman, Quezon City
www.iecep-qcchapter.org Paste
Email: secretariat@iecep-qc.org updated
1”x 1“
colored ID
MEMBERSHIP FORM picture here

MEMBERSHIP NO. ______________ CHAPTER AFFILIATION: __QUEZON CITY CHAPTER___

Please put ”x” in
appropriate box NEW RENEWAL ASSOCIATE LIFE UPDATE

FULL NAME: __________________________________________________________________

(SURNAME) (FIRST NAME) (MIDDLE NAME)
PRC LICENSE NO. ( PECE ECE ECT) ____________ DATE OF EXAM _______________ PRC ID VALIDITY ______________
(MM/DD/YEAR) (MM/DD/YEAR)

BIRTHDATE: _________________ PLACE OF BIRTH: _______________________________________ BLOOD TYPE: ____________

(MM/DD/YEAR) (MUNICIPALITY/CITY/PROVINCE)

HOME ADDRESS: ___________________________________________________________IN CASE OF EMERGENCY

____________________________________________________________________________________ ZIP CODE: _____________
CONTACT DETAILS
EMAIL ADD OFFICE ________________________________________ TELEPHONE / FAX NO ____________________________
PERSONAL ________________________________________ MOBILE NO ____________________________
IN CASE OF EMERGENCY
CONTACT PERSON ________________________________________ MOBILE NO ____________________________

EDUCATIONAL ATTAINMENT
DEGREE SCHOOL YEAR

BUSINESS DETAILS
COMPANY NAME: _________________________________________________ JOB POSITION __________________________________________
COMPANY ADDRESS:____________________________________________________________________________________________________________
_______________________________________________________________________________ ZIP CODE: ________________
TELEPHONE: ____________________________________________________ FAX: _______________________________________________________
FIELDS OF EXPERTISE: (YOU MAY TICK MORE THAN ONE)
Academe Electronics Military
Broadcasting Government Power Sector
Construction Information Technology Semiconductor
Consultancy Management Telecommunications
Computers Manufacturing Others ___________________________________

SALARY RANGE:
Php 60,000 and above Php 50,000-59,999 Php 40,000-49,999
Php 30-000 to 39,999 Php 20,000-29,999 Php 20,000-below

SIGNATURE: _____________________________________ DATE: _________________________

FOR IECEP SECRETARIAT USE ONLY

MEMBERSHIP NO.: ____________________________________ CGS NO.: ___________________________________

OFFICIAL RECEIPT NO.: ____________________________________ AMOUNT: ___________________________________
TRACKING NO.: ____________________________________ BACKDUES: ___________________________________