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
Mobile No. 0917.805.5052 | E-mail: iecep.pampanga.org@gmail.com | Website: www.iecep-pampanga.org

REGISTRATION FORM
CPD 2018-01 / IECEP Pampanga IECEP Pampanga Use:
CPD
Program: 1st CPD Seminar and Induction of 2018 BODs I. Payment

☐ BANK
Deposit # ______________
“Structured Cabling: Standards and Practices” ” Amount: _______________
Seminar/s: by Engr. Edwin A. Sta. Maria, PECE, MBA. Date: _________________
OR # _________________
(8 CPD Units) Received By: ___________

Date/Time: February 24, 2018, Saturday / 7:30AM – 5:30PM ☐ CASH

OR #: _________________
Venue: Casa Nena, Saint Therese of Liseux Building, Holy Angel University, Angeles City.
Amount: _______________
☐Member ☐Life ☐Associate ☐Non-Member ☐PECE ☐ECE ☐ECT Chapter: Received By:___________
Date: _________________
IECEP No.: Validity: PRC No.: Validity: Exam Date: ………………………………
First Name Middle Name Surname Ext.
II. Records

☐ Membership verified
Date of Birth: Status: Gender: Blood Type:
☐ Seminar Kit issued
Email1: Email2: ☐ Attendance signed
Phone1: Phone2: Phone3: Zip Code: ☐ Database updated
Home Address Line 1 Address Line 2 Town / City Province Country ………………………………
Remarks:
______________________
Preferred Address (Same as above? ☐) Birth Place (Province/Country):
______________________
Preferred Address Line 1 Address Line 2 Town / City Province Country / Zip Code
______________________
______________________
………………………………
Company: Preferred Address ☐
BANK ACCOUNT:
Position: Start Date: End Date:
Account Name:
☐Employee ☐Owner Type of Industry: Zip Code: IECEP PAMPANGA
Company Address Line 1 Address Line 2 Town / City Province Country Bank Account No.:
008733-0410-65
Phone1: Phone2: Work Email: Bank Address:
Bank of the Philippine
School: Year Grad.: Islands (BPI), Balibago,
Degree: Angeles City.

REGISTRATION GUIDELINES
1. Please accomplish this form and submit it to any IECEP Pampanga Chapter BODs or representatives.
 Payment through Bank/Online transfer: 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. Delegate’s 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 the IECEP Pampanga Chapter Secretary, 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.