INSTITUTE OF ELECTRONICS ENGINEERS OF THE PHILIPPINES, INC.

(IECEP) PAMPANGA CHAPTER

c/o ECE Department, College of Engineering and Architecture, Holy Angel University
#1 Holy Angel Avenue, Sto. Rosario St., Angeles City, Philippines 2009
Mobile No. 0917.805.5052
E-mail: iecep.pampanga@yahoo.com Website: www.iecep-pampanga.org

REGISTRATION FORM
CPD
Program:

For Early Bird Registration:

CPD 2016-04 / IECEP Pampanga

Polo Shirt Size

4th CPD Seminar

( Winner Brand )

Seminar/s:

Date/Time:

December 3, 2016, Saturday / 8:00AM 5:00PM

Venue:

Casa Nena, Holy Angel University, Angeles City.

Member Life Associate Non-Member

IECEP No.:

Validity:

Exam Date:

Surname

Status:

Gender:

Email:

Ext.

Blood Type:

Work Email:

Phone1:
Home Address Line 1

Validity:

Middle Name

Date of Birth:

BANK
Deposit # ______________
Amount: _______________
Date: _________________
OR # _________________
Received By: ___________

PECE ECE ECT Chapter:

PRC No.:

First Name

I. Payment

XS to XXL Only

Fire Detection & Alarm System" (4 CPD Units)

by Engr. Luis T. Lina
Project Management" (4 CPD Units)
by Engr. Melvin C. Acosta

Phone2:
Address Line 2

Phone3:
Town / City

Zip Code:
Province

Country

Preferred Address (Same as above? ) Birth Place (Town/Province):

Preferred Address Line 1

Address Line 2

Town / City

Province

Company:
Start Date:

Employee Owner
Company Address Line 1

Phone1:

Country / Zip Code

Preferred Address

Position:
Type of Industry:

Address Line 2

Zip Code:
Town / City

Phone2:

End Date:

Province

Country

Fax:

School:

Year Grad.:

Degree:

IECEP Pampanga Use:

CASH
OR #: _________________
Amount: _______________
Received By:___________
Date: _________________

II. Records
Membership verified
Seminar Kit issued
Attendance signed

Remarks:
______________________
______________________
______________________
______________________

BANK ACCOUNT:
Account Name:
IECEP PAMPANGA
Bank Account No.:
008733-0410-65
Bank Address:
Bank of the Philippine
Islands (BPI), Balibago,
Angeles City.

REGISTRATION GUIDELINES
1. Please accomplish this form and send to IECEP Pampanga Secretariat or any IECEP Pampanga representative.
Payment through bank: Delegate must provide scanned copy of IECEP ID and DEPOSIT SLIP/ONLINE TRANSFER TRANSACTION to
iecep.pampanga.cpd@gmail.com together with this accomplished form. Delegates Name must be indicated on the deposit slip/transfer record.
2. Attendance will be permitted upon receipt of completed registration form and full payment.
3. Cancellation and Refund: All cancellations should be made in writing and addressed to IECEP Pampanga Secretariat one week before the scheduled event for
a 50% refund. No refund shall be made for any cancellations made after. No refund shall be made for cases of non-attendance.