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North Carolina Society of Engineers Membership Application

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Form of Application for Membership and Qualification Record

North Carolina Society of Engineers

P.O. Box 984 - Garner, N.C. 27529-0984 Phone: 919-639-8896

I,_______________________________________________________________

Last First Middle

hereby apply for membership in the North Carolina Society of Engineers. I am enclosing a check

for $__________ to cover the first year's dues, which I understand will be returned to me if not

elected a member of the Society. ( $2.00 students $60.00 regular or associate)

Grade of Membership applied for:______________________________County______________

(Regular, Associate, Student. See Bylaws for Definitions)

Branch of Engineering:__________________________Registered Engineer : Yes_____ No_____

State : ___________Reg. No. : ________

Occupational Title : _____________________________Date of Birth:_______________________

Employer : ____________________________________Work Phone :_______________________

Full Business Address :__________________________Home Phone :______________________

_____________________________________________ Fax :______________________________

Full Home Address :_____________________________E-Mail :____________________________

__________________________________ Cell Phone:_______________________

Present Membership in Technical Societies :

Society :______________________________________Grade of membership :________________

Provide the name of the NCSE member securing application, or other source of application, (website, etc.).

Name:________________________Title:_________________Full Address:____________________

(NCSE Member or other source of application)

Name:________________________Title:_________________Full Address:____________________

(Reference - Engineer or Employer name)

I certify that the above statements are correct to the best of my knowledge and belief. When elected,

I will be governed by the Constitution, Bylaws, and Rules of the Society and I will promote the interest

of this Society to the best of my ability.

Signature of Applicant:________________________________Date:___________________

Education: (use separate sheet, if needed)

Dates

From To School Location Course Did you graduate?

________________________________________________________________________________

Professional Experience Record: (Use separate sheet, if needed)

Dates Title Employer Brief Description of Duties/Responsibilities

From To __________________________________

_______________________________________________________________________________

__________________________________

_______________________________________________________________________________

TO BE COMPLETED BY NCSE EXECUTIVE DIRECTOR:

Application received_______________20____ Application elected _____Date__________20_____

to membership with grade of:__________________ Date:_________________Check #_________

Amount:__________