ERC/AF/01

GOVERNMENT OF MALAWI
MALAWI ENGINEERING INSTITUTION
(Malawi Engineering Institution Act, 2019)

ENGINEERING REGISTRATION COUNCIL

To: The Registrar

MEMBERSHIP APPLIC~A~T~IO~N~FO~R:M:___ _ _ _ _ _ _ _ _ _ 7
Engineering Registration Council FOR OFFICIAL USE ONLY
P. 0. Box 30228, Capital City Application No: ................................................................................
Lilongwe 3
Date Received: .....................................................................................
Email: info@mei. [Link]
Website: [Link].m w Application fee Receipt No: ................................................. ..

Telephone: +265 789 114 Remarks: ······························••••••••••••••••••••••••••••• ••

············································•••••••••••••••••••••••••••••••• •••••••• •••
PERSONAL INFORMATION (Use capital fetters only and names should be entered as they appear in the certificate s)

1. Full names of the applicant: Prof./Dr./M r./Mrs./Mis s

(a) Surname
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(b) First Names
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k"C.O .................
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r.,...................................................................
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2. (a) Date and Place of Birth

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(b) Nationality
......M
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*Attach a national identification document
3. Sex
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...~..... 1..1................
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4. (a) Permanent Address

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(b) Present Employer and address
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(c) Telephone Number: .......f..2:,§..[Link].1.-R.~§.~................................................................,

(d) E-mail Address: ......... [Link]:[Link]~.(':?f.~@.~.~f)J.t:.CP.t:':\.................................................

5. Class of membership applied for:

1
 uAU FIC ATI ON
p,.CA
0Etv 1IC a
ERC /AF /01
.,. . . d copi es of cert ifica tes etc.
ert1f1e ; if not certi f" d .
(,Atta cll c ie avai l o •
insti tutio n and place of stud y ngin als to the Boar d for verif icati

-
on}
Nam e o f
Cour se of Stud y
Years of Atten danc e Qual ificat ion Attai ned
(Deg ree/D iplom a etc)

f ur'[Link]'& 1t-C-H-N1 CA-L l~NI

Ct u\L fNG i6,
QOl°t Qo~.3 bG~R-BB

7. ENG INE ERI NG DIS CIP LIN E

(Ele ctric al, Civil , Mec han ical
Aero nau tical Agr,· c It
' , u ura 1, etc.}

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8. MEM BER SHI P WIT H OTH ER
ENG INE ER
ING PROFESSIONAL INS TITU TIO
NS/ COU NCI L
Nam e of Engi neer ing
I nstit ution a I/Asso ciati on/B oard
/Cou ncil
NI A
Coun try Class of Mem bers hip or
Regi strat ion
regis tratio n Num ber Date

9. MEM BER SHI P WIT H OTH ER

PROFESSIONAL INS TITU TIO NS
OTHER THA N ENG INE ERI NG INS
TITU TIO NS tµ/ I
Nam e of Engi neer ing
Class of Mem bers hip or Regi strat ion
Instit utio na I/Asso ciati on/B oard Coun try
/Cou ncil regis tratio n Date
Num ber

2
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5
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>es'n w I ond yw), Desec;pt· e IS not sufficient)
perlOd
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from ...,.J ~N........To....~ ..tJ......... Qo'2.:, 1

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' cu ng Your Personal responsiblllty/achlevement

d address of employer: J'tJ. R" r_ 't I

'Name an
l,lf\A (3[ ~ """ ei~tiuf ./

7 fs1 I 10 e STR.ftJB1H
tt~t::, ~uRI\Br uT't
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Your Position: Oto
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rs [Link] g c -rHe1 fl.I< c

Name of supervisor:

FooT/rJ~ do-u.rT1<t1 o?lo"}

~Pe::-:r:;-:io:::;d,:(m;::::~on~t~h-;a~ndrl~ywe!aarrl):: I DQ,pe~s,-;.:c;:;;ripMt;-;;io:;:;-n-;::-o~fy::::o;--::ur~uding your personal responsibility/achievement

From ••••• d.Ul1...To...Aµ_§:....Qo~'
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Name and address of employer:
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u rv'\E lf'. A ei \~ o u P
t." It1 Cb tvJ1i<M <!ff o,J
Your Position:
Fr>Rrv\:fi) DI'<(-<.. •[Link] l-Lf)TIOl\l

IM l 7\JEf
Name of supervisor:
t:fV~\N(tR__

Period (month and year):

Description of your work, [Link].g your perso
• n;il responsibility/achievement
rrom •••••••..•.............To .................... .

Name and address of employer:

Your Position:

I Nome of supecvlsoc

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3
 --------------------
ERC/AF/01
oNS OR PAPERS/TECHNICAL REPORTS WITH DATES (If Any)
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(b)
·····••••••••••••••••••••••••••••••••.................................···········..............................................................................
(c)
................................................................................................................................................................

DECLARATION BY THE APPLICANT

12.
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••••••••••••••••••••••••.......................................................................................................................................
(Name in full, in block letters and underline Surname)

of
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••••..•. 11...... A-t--G /Vllr/lJQ.,ocH
...., ....................... I
............................................... .............................
{Permanent Address)

hereby apply for registration on the Register of Engineers and submit herewith:

(a) a prescribed Statutory Declaration in support of the Application;

(b) the prescribed application fee of K

...So, r;"l5l)
....... ..,................................ .......................................
(c) the following certified copies of degree/professional/diploma/certificate(s) in support of my
application:

.....uA C1'..
~ ..................................
l!-.Ef; ~ .......................... ., .... ., ............ .....................................................................

······················································~·······················:·························:·························································

Dated:
-~·········a¥.·~·~·····································
Signature of Applicant