First Name:

Last Name:

Home Address:

Postal Address:

Email Address:

Phone Number:

Field of Engineering:

Select Month and Year of Graduation



Professional Qualification:

NIMMME Membership Number:

NSE Membership Number:

COREN Membership Number:



How long have you been a Corporate Member of NIMMME?

Are financially up to date with NIMMME?

Are your referee forms mailed?

* Names of two Fellows or SPX as Referees

Is your report closed as required?

Have you fascilitated membership for any two financially up to date student/
corporate member? If yes, state them:

Have you attended any of your Chater meetings, if yes,
state up to 5 meetings within last two years?

Have you served in any Office or Committee of your Chapter
or Institution? If yes, give details

Have you attended NIMMME National Annual General Meetings?
If yes, state dates and places of up to 3 AGM within the last 10 years

Have you attended any Technical or Management Seminars, Lectures, Workshop
or Conference? Please state below (Date and places of up to three)

Have you written, presented or publsihed any Technical/Management Papers?
If yes, give details of Titles, Dates and Places.

Have you held any NIMMME National Executive Office?
If yes, state position and period.

Have you served on NIMMME or NSE Council or any Council Committee / Board?
If yes, give details.

Have you represented NIMMME or been appointed to any Federal /
State Government Board, Committee, Task Force, etc?

Have you held any recognized position in your field of Engineer or public/private office
for at least 2 years (e.g. Minister, Commissionder, Adviser, Permanent Secretary,
Director General, MD, GM, Director, Dean, HOD, Principal Partner, Chief Princiopal
Consultatant, Peofessor, etc? If yes, state position and period.

State any contribution (with evidence) you made in any of the following areas:
a) Inventions/Patents, b) Basic modoification to Engineering System, c) Major Design,
d) Special Technical/Scientific/Management Study.

I affirm that the information above is true and correct. I also re-affirm my pledge
to comply with the constitution, bye-laws, rules, procedures and codes of ethics
(State your full name and date)