ASEAN CHARTERED PROFESSIONAL ENGINEER

Republic of the Philippines

APPLICATION FORM
Professional Regulatory Board of _____________________________
ELECTRICAL ENGINEERING

1. First Name _______________

SAMMY Surname _____________Middle
DUMAYA Name ____________
EVANGELISTA
Date of Birth ____________________________
December 18, 1966
Age ____________________________
50
Gender ____________________________
Male
Civil Status ____________________________
Married
Place of Birth ____________________________
Nueva Ecija
Nationality ____________________________
Filipino
Taxpayer's Identification No. ___________________
101-528-738
SSS/GSIS No. ____________________________
02-0851834-9

2. Home Address ____________________________________________________

Zone 5, Natatas, Tanauan City, Batangas
Postal Code ____________________________
N/A
Tel./Fax ____________________________
N/A
E-Mail Address ____________________________
se_dumaya@yahoo.com

3. Company Name ____________________________________________________

Technip Middle East
Address ____________________________
Home Center Bldg, Doha, Qatar
Postal Code ____________________________
P.O. Box 2119
Tel./Fax ____________________________
+974 44532457
E-Mail Address ____________________________
sdumaya@technip.com

4. Education (Attach all Diplomas, Certificates and Transcript of Records)

Baccalaureate ______________________
BSEE School _______________
NEUST Year _______
1988
Post Baccalaureate _________________
- School _______________
- Year _______
-
Doctoral ___________________________ School ________________ Year _______
- - -
Post Doctoral ______________________ School ________________ Year _______
- - -

5. PRC Registration No. ____________________________

PEE - 3387
Issued on ____________________________
May 17, 2016
Valid Until ____________________________
December 18, 2019

6. Professional Tax Receipt No. _____________________

2147643
Issued on ____________________________
May 24, 2016
Issued at ____________________________
Tanauan City, Batangas

7. Specialized Training relevant to the Field of Expertise

Title of Training __________________________________________________________
ETAP 114 Power System Analysis
Institution and Address _______________________________________
ETAP Automation DMCC Year _______
2015

Title of Training __________________________________________________________

Tropical Helicopter Underwater Emergency Training (T-HUET)
Institution and Address _______________________________________
Venture Gulf Training Center Year _______
2016

Title of Training___________________________________________________________
Basic H2S
Institution and Address_______________________________________
Venture Gulf Training Center Year _______
2016

IAD-08
Rev. 00
July 7, 2016
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