Piqc Diploma Registration Form

PROFESSIONAL TRAINING PROGRAMS

APPLICATION FORM Please (

) the appropriate

PHOTOGRAPH

r Certified Quality Professional r Certified Human Resource Professional r Certified Software Quality Professional

(Passport Size)

A. PERSONAL DATA NAME Mr. Ms.

Mrs.

JOB APPOINTMENT: COMPANY: OFFICE ADDRESS: HOME ADDRESS: DATE OF BIRTH (Day/Month/Year)

N.I.D. NUMBER:

HOME PHONE:

WORK PHONE:

E-MAIL:

FAX:

B. EDUCATION

(Attach your credential with the application)

DEGREE

DATES ATTENDED

COLLEGE/UNIVERSITY (Name/City/Country)

From (year)

To (year)

NO OF ACADEMIC YEARS

GRADE/ DIVISION

C. SUMMARY OF PROFESSIONAL EXPERIENCE POSITION

EMPLOYER

DURATION From (year)

To (year)

YEAR IN POSITION

D. TECHNICAL TRAINING/COURSES DESCRIPTION OF TRAINING/COURSE

INSTITUTION

DURATION

DATES ATTENDED From (year)

To (year)

PROFESSIONAL TRAINING PROGRAMS

E. PROFESSIONAL MEMBERSHIP TYPE OF MEMBERSHIP

PROFESSIONAL BODY

MEMBER SINCE

F. EMPLOYER`S APPROVAL (In case the candidate is sponsored by the company) 1. I certify that the information provided by the candidate is accurate to the best of my knowledge. 2. I have no objection whatsoever on the candidate's admission and participation in the course.

EMPLOYER`S STAMP & SIGNATURE

NAME

DATE

G. REFERENCE (I personally know the candidate and recommended him/her for this Professional Training Programs) Reference 1:

Reference 2:

Name:__________________________________

Name:__________________________________

Designation:_____________________________

Designation:_____________________________

Company Name :_________________________

Company Name :_________________________

Address :________________________________

Address :________________________________

_______________________________________

_______________________________________

Phone No._______________________________

Phone No._______________________________

E-mail: _________________________________

E-mail: _________________________________

SIGNATURE

SIGNATURE

H. CANDIDATE`S VALIDATION I certify that the statements above including my attachments are accurate to the best of my knowledge. I hereby authorize the Institute to verify any information submitted. I understand that any falsification of any information in this application or attachment may cause for rejection or withdrawal of admission. I further agree to hold the PIQC harmless from any and all liability in the event this application is rejected on the basis of information furnished by me or third person which would make me ineligible. I further agree to adhere to the PIQC's Code of Professional Conduct and, if I am certified, to meet the requirements of continuous certification.

SIGNATURE

DATE

I. DOCUMENTS TO BE ATTACHED (Please ensure that the following documents have been attached and tick appropriately)

q q q

Passport Size Photographs (two) Professional Degree(s)/ Provisional Certificate(s) Photocopies Biodata/ Resume

H. CANDIDATE`S VALIDATION THE APPLICATION HAS BEEN APPROVED

THE APPLICATION HAS BEEN REJECTED

REVIEWER/APPROVER:

DATE:

SIGNATURE