APPLICATION FOR ELECTION OR TRANSFER THIS …

1 Page | 1 APPLICATION Form 2013 The South African Institute of Electrical Engineers Innes House, 18A Gill Street, Observatory, Johannesburg, 2198 P O Box 751253, Gardenview, 2047 Tel +27-11-487-3003 Fax +27-11-487-3002 Web: Account enquiries: Celeste Pretorius : Membership registrations: Tracey Human: APPLICATION FOR ELECTION OR TRANSFER TO ASSOCIATE/MEMBER/SENIOR MEMBER (Office Use Only) APPLICATION received on: Present Grade: since: Graded by Council as: Date of Meeting: NOTE: THIS FORM MUST BE COMPLETED IN BLOCK LETTERS, SIGNED AND EITHER FAXED BACK TO 011-487-3002 OR SCANNED AND EMAILED TO (Do not return without a signature, requested documents & proof of payment as per page 2) Your Personal Details: Surname: First names: Title: Date of Birth: ID Number: Country of Citizenship: Contact Details: Physical Address: Postal code: Postal Address.

2 (if not same as physical) Postal code: Employer Name and Address: Home: Tel: Fax: E-mail: Office: Tel: Fax: E-mail: Mobile: Name and tel no. of a contact person (Not living with you): Education/Miscellaneous: ECSA Registration No.: First Relevant Qualification Achieved (degree/diploma/GCC) Graduation date of first relevant qualification: Name of University/Technikon/College: Relevant Experience After First Qualification: (years): IF YOU HAVE A FOREIGN QUALIFICATION PLEASE PROVIDE A CERTIFIED COPY OF SAQA CERTIFICATE OF EVALUATION TOGETHER WITH A CERTIFIED COPY OF YOUR ORIGINAL QUALIFICATION Present grade of membership of the SAIEE (if applicable).

3 Page | 2 APPLICATION Form 2013 APPLICATION for ELECTION / TRANSFER as Associate/Member/Senior Member DECLARATION BY APPLICANT: I the undersigned, hereby declare that I will be governed by the Constitution and By-laws of the South African Institute of Electrical Engineers now in force or as they may be amended. I will advance the objectives of the Institute. While a member of the Institute, I will adhere to the code of professional conduct laid down in the Constitution. (A copy of the Constitution, By-laws and Objectives are displayed on the website: ). I also declare that the statements made by me on this form are true and correct.

4 SIGNATURE OF APPLICANT:..DATE: .. Applicants for the grade of Associate or Member are required to nominate a member of the SAIEE or a senior company official who would be prepared to vouch for the applicant s professional experience and integrity. (Please enter the contact details of this person below). Name: Tel: Mobile/Cell: Email: SAIEE Membership No. Relationship with Applicant Applicants for the grade of Senior Member are required to nominate at least two Senior Members or Fellows who would be prepared to vouch for the applicant s professional experience and integrity.

5 (Please enter the contact details of these persons below). Name: Tel: Mobile/Cell: Email: Name: Tel: Mobile/Cell: Email: A certified copy of your degree/diploma must be submitted together with the completed form. Payment of the Entrance and Membership Fee for the appropriate grade must accompany this APPLICATION (Refer to website for Membership Subscription Rates). Payment can be effected by cheque, electronic TRANSFER or credit card. Bank details. Standard Bank, Ellis Park Branch Code: 00 46 05 Account Number: 201 547 066 Please email proof of payment to Celeste Pretorius at Credit Card Details: Card Number.

6 Expiry Date: .. CVC Number: .. (Last 3 digits on reverse side) .. Amount to pay: .. TO AVOID DELAY, BEFORE SUMITTING YOUR APPLICATION PLEASE CHECK THAT YOU HAVE DONE THE FOLLOWING:- 1. Completed the APPLICATION Form in full 2. Attached CERTIFIED COPIES of your relevant qualifications 3. Attached a copy of your latest CV 4. Attached a copy of your id 5. Attached proof of payment of APPLICATION and annual membership fees