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Date: 13.11.2016
FORM A3-2
FORM A3-2
APPLICATION FOR REGISTRATION AS AN Applicant's
current
INSPECTOR OF WORKS passport size
Section 10E of the Registration of Engineers Act 1967 (Revised 2015) photo
MALAYSIAN 750819-14-5017
Nationality : ................................................ Identification Card No. : ....................................................................
NO 41, JLN SG KLANG, 32/21, BERJAYA PARK, SEKSYEN 32, SHAH ALAM, 40460,
SELANGOR, MALAYSIA
Address in Malaysia (if any) : .....................................................................................................................................
+603 5131 6274 +6019 2547713 -
Tel. No.: ....................................... Mobile Phone No.: ............................. Fax No: .................................................
-
Postal Address (if different from above) : ....................................................................................................................
mohd.dzamir@gmail.com
E-mail Address : .......................................................................................................................................
DIPLOMA IN WELDING TECHNOLOGY, CSWIP 3.2.1 SENIOR WELDING INSPECTOR,
Qualifications : .........................................................................................................................................
CSWIP 3.4 RADIOGRAPHY INTERPRETER, ASNT MT & PT LEVEL II
…................................................................................................................................................................
FORM A3-2
APPENDIX - A
BRANCH OF ENGINEERING
Listed below are branches of engineering registered by the Board of Engineers Malaysia.
Civil ¥ Mechanical
FORM A3-2
DECLARATION TO BE SIGNED BY THE APPLICANT
a) I, the undersigned, apply for registration as a Inspector of Works and if am registered, I agree to abide by :
i. The Registration of Engineers Act 1967 (Revised 2015) and The Registration of Engineers
Regulations 1990 (Revised 2015) ; and
ii. Notifications and Circulars issued by the Board of Engineers Malaysia.
b) I hereby authorize the Board of Engineers Malaysia to seek clarification on any information submitted in
any manner and by any means as it deems fit and proper.
Suffix : ..………………………………………………
Rev. No.: 1
Date: 13.11.2016
FORM A3-2
APPENDIX A
1/2
SUMMARY OF EMPLOYMENT ( Page No. ….........)
Please detail the main duties you have performed with emphasis on the most recent years proceeding your
application.
FORM A3-2
APPENDIX A
SUMMARY OF EMPLOYMENT ( Page No. ….........)
2/2
Please detail the main duties you have performed with emphasis on the most recent years proceeding your
application.
July 2017- Apave Malaysia Technical Performing 2nd Party & Mohammad Tahir
present S/B Representati 3rd Party inspections Bin Md. Yussof
ve Services Director of BD &
Operation
(BEM: 12914A)
December 1998
I hereby declare that I have worked as an Inspector of Works since ….......................................................
oil & gas mechanical constructions I certify that the above information provided are to the
in the field of …................................................................
best of my knowledge, accurate and correct in all respects.
…......................................................
(Signature of Applicant)
Date :
FORM A3-2
Current
position: DIRECTOR OF BUSINESS & OPERATION
…...................................................................................................................................................
MANAGING THE OPERATION AND TECHNICAL TO ENSURE THE WORKS PERFOMED
Responsibility : …...................................................................................................................................................
WERE COMPLIED TO THE REQUIRE REGULATION, CODE & STANDARD AN OTHER
…...................................................................................................................................................
SUPPLEMENTAL WHICH IS REQUIRED BY CONTRACT SPECIFICATION.
…...................................................................................................................................................
…...................................................................................................................................................
…...................................................................................................................................................
2 YEARS
Tenure of Office …...................................................................................................................................................
I certify that the information provided is, to the best of my knowledge, accurate and correct in all respects.
Signature:
…............................................................
12914A
(*Professional Engineer No. / Graduate Engineer No. …..........................................)
Date: …..................................................
CHECKLIST
(To be submitted together with Form A3-2)
Tick (√) if it is applicable and has been fulfilled. Cross ( X ) if it is not applicable.
Remarks :
….............................................................................................................................................................................
….............................................................................................................................................................................
I confirm that I have completed the above and fulfil BEM For Office Use Only
requirements.
Signature of Officer-in-charge
Board of Engineers Malaysia
…........................................................................................
(Signature of Applicant) ….....................................................................
Date : Date :