Please complete all sections of the form.
Once completed, please save a copy and submit this form via email to: [email protected] OR print and post a copy to: Membership Department, CIBSE, 222 Balham High Road, SW12 9BS, UK.
QUALIFICATION ASSESSMENT FORM
Please complete all sections of this application form
and ensure that copies of qualification certificates,
transcript listing subjects you undertook and examination
marks, and synopsis of MSc/PhD thesis (if applicable) are
attached and the required payment is included.
PERSONAL DETAILS
Please note that if you are not already a CIBSE member,
the cost of assessing your qualifications is 40.00.
Date of Birth 28
D D / 08
M M / 83
YY
If you are already a CIBSE member there is no charge.
Title Mr
First Name(s) RAHOOF
Surname MOODOLI
Home address MOODOLI HOUSE
POAT KARIYAD SOUTH
Post code 673316
KERALA, INDIA
Country INDIA
QUALIFICATION ASSESSMENT FORM
Telephone No 0091-490239480
Please indicate whether:
Fax No
New (not previously a member of CIBSE) or,
Email [email protected]
Existing member
Mobile No 00918157040328
Grade
Membership Number
Company name GHARNATA CONSULTANT
Please indicate which level of Engineering Council Registration
you are interested in and would like CIBSE to assess your
qualifications against:
ENGINEERS
Work address 2nd
FLOOR, ARAMEX COURIER BUILDING
ABU HAMOUR
Post code 24436
Engineering Technician (EngTech)
DOHA, QATAR
Country QATAR
Incorporated Engineer (IEng)
Telephone No 00974 70354267
Chartered Engineer (CEng)
Fax No
Email [email protected]
Preferred mailing address
Home
Work
Preferred email address
Home
Work
EDUCATIONAL QUALIFICATIONS
Please list all your post school qualifications below and indicate any exemptions granted and details of any interruptions to your course.
Awards shown must be accompanied by a photocopy of the original certificate countersigned by your Sponsor as having seen the original.
University or
College
CALICUT
UNIVERSITY
Full title of qualifications
gained including
subject area
BACHELOR OF
TECHNOLOGY IN
ENGINEERING, IN
BRANCH
MECHANICAL
ENGINEERING
Date course
commenced
Course
duration
Date
qualification
obtained
Mode of Study
JUNE 2001
4
YEARS
JUNE
2005
F/T
(F/T, P/T, sandwich,
etc.)
Year of entry
to course
(i.e entered in year 1 or
2, 3 due to exemptions)
1ST YEAR
If your qualifications are not accredited for EngTech you will be required to participate in an interview assessment.
QUALIFICATION ASSESSMENT FORM
Page 1 of 2
APPLICANTS DECLARATION
SUBMITTING YOUR ASSESSMENT FORM:
I certify that the information in this application and supporting
documents are correct. I agree that, in the event of my election
to any class of membership of the Chartered Institution of Building
Services Engineers, I will be governed by the provisions of the
Royal Charter and By-laws as they are now formed or as they
may be hereafter altered; that I agree to abide by the Code of
Professional Conduct, which can be found at www.cibse.org/code,
and do all in my power to advance the objects of the Institution;
providing that whenever I shall signify in writing to the Director
of Membership that I wish to withdraw from the Institution,
I shall, after payment of any arrears which may be due by me
at that period, be free from this obligation.
You can submit a printed copy of this form along with
attachments via post or an emailed copy with attachments using
the details below;
Signature Date
RAHOOF
D D / 10
M M / 15
YY
18
MOODOLI
Digitally signed by RAHOOF MOODOLI
DN: cn=RAHOOF MOODOLI, o=GHARNATA
CONSULTANT ENGINEERS, ou,
[email protected], c=QA
Date: 2015.10.18 15:28:49 +03'00'
POSTAL ADDRESS
Membership Department
Chartered Institution of Building Services Engineers
222 Balham High Road, London, SW12 9BS, UK
EMAIL ADDRESS
[email protected]
Telephone +44 (0)20 8772 3650 | Fax +44 (0)20 8675 5449
Registered Charity No. 278104
CIBSE HQ USE ONLY:
NB. In the event of it coming to light that information supplied on this form is inaccurate,
CIBSE reserve the right to withdraw membership of the Institution and discipline the
applicant under the Code of Professional Conduct.
FEES
Payment can be made by cheque payable to CIBSE or by completing
the debit/credit card details below:
Please tick:
Mastercard
Visa
Visa/Delta
Maestro
Please note: we do not accept Amex or laser cards
Card Number
Valid from M M / Y Y
Issue Number (For Maestro only)
Expiry Date M M / Y Y
Security Code
Address details card is registered to
Post code
Country
Please debit card to the amount of
Signature of Cardholder
Date
QUALIFICATION ASSESSMENT FORM
DD / MM / YY
Page 2 of 2
