ECSA

Topics: Engineering, Engineer, Professional Engineer Pages: 14 (2239 words) Published: June 18, 2014
ENGINEERING COUNCIL OF SOUTH AFRICA(17/05/2012) Form B1.1

Private Bag X 691Waterview Corner, 1st Floor,
BRUMA 20262 Ernest Oppenheimer Avenue
Tel:(011) 607-9500Bruma Lake Office Park
Fax:(011) 622-9295BRUMA
Email:engineer@ecsa.co.zaJohannesburg
Website:www.ecsa.co.za2198

A P P L I C A T I O N F O R M
REGISTRATION AS A PROFESSIONAL ENGINEERING TECHNOLOGIST NB:Please consult the Information Sheets (Sheets B1.1 & B1.2) before completing this Application.

1.General Information:
Surname:
Oliver

First Names:
Jason Grant

PHOTOGRAPH
(Passport-type.
Please paste - do not staple)

Alternatively, insert electronically in JPEG or similar format Date of Birth:
12/12/1978

Identity No:
7812125134081
or

*Race Group:
Please tick the
applicable block
Asian
Black
Passport No.
and Country:

Country of normal residence:

Coloured X
White

Home Address:

16 Castellano Private Estate
Cedar Avenue West
Broadacres
Fourways

Postal Address:

16 Castellano Private Estate
Cedar Avenue West
Broadacres
Fourways

Name & Address of present Employer:
TUV Nord Southern Africa (Pty) Ltd.

Tel. No. (Home): N/A

Tel. No. (Work): (021) 521 6800

Cell No.:0835663944

E-mail: jaoliver@tuv-nord.com

Title of Position held:
Mechanical Engineer
Tel. No. (Employer): (021) 521 6800

Fax No.: (include area codes)

E-mail:

*Completion of this section is necessary in order to accurately reflect equity statistics in terms of Government Policy.

2.Qualifications: (All qualifications at tertiary level) (List of subjects to be provided on Form B1.3) Educational Institution
Qualification
Attendance
fromto
Date of final
examination
Office
use

NB: Kindly initial this page in the presence of a Commissioner of Oaths / Justice of Peace.

Commissioner Of Oaths/
Applicant: ………………………….Justice Of Peace:………………………………………
-2-(17/05/2012) Form B1.2

3.Previous / Current Registration or Application Details: (eg. Candidate Engineering Technologist, Registered Lift Inspector, etc.)
Type
Category
Number
Date

Previous Registration:

Current Registration:

Previous Application:

4.Membership of Voluntary Associations recognised in terms of Act No 46 of 2000 (or other): (If more space is needed, please supply information separately.) Name of Association / Institute / Society

Membership grade
and date accepted
Number of years
Office held

5.Application Fee: (See item 5 of the Information Sheet)

My Application fee of R (cheque) is transferred electronically.

6.Referees:
(1)

E-mail:
Tel No:
(2)

E-mail:
Tel No:
(3)

E-mail:
Tel No:

7.Declaration:

I, (full names)
hereby apply for Registration as a Professional Engineering Technologist and undertake to abide by all the provisions of the Engineering Profession Act, 2000 (Act No. 46 of 2000) and any Rules published thereunder, including the Code of Professional Conduct. I declare that Section 19(3)(a) of the Act does not preclude me from registration. I solemnly declare that, to the best of my knowledge, all the information contained herein is true.

Signature: __________________________

Sworn to/Affirmed before me at ___________________________

on this the ________ day of _____________________(month & year).

Commissioner of Oaths/
Justice of Peace: ………………………………………………(Commissioner’s stamp)

Office Use Only

Application fee:R ______________________

Received by:________________________Date: ______________________

(Council’s stamp)
Engineering Council of South Africa(17/05/2012) Form B1.3

Detailed information on

TERTIARY ENGINEERING QUALIFICATIONS

Professional Engineering Technologist

Name...
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