i n s t i t u t e o f c o r r o s i o n（我t u n s t e o f c o r r o s i o n）（20页）.doc

INSTITUTE OF CORROSION The Newton Building, St George’s Avenue, Northampton, NN2 6JB TEL: +44 (0) 1604 893883 - FAX: +44 (0) 1604 893878 E-mail: admin@ Web site: SENIOR Cathodic protection ENGINEER level 3 certification Application in accordance with BS EN 15257 TYPE or PRINT in black ink. This form is available in e-format from . Note that this form will be photocopied. Please send your completed form, copies of Certificates and supporting documents(see Guidance Notes) to: Institute Of Corrosion, CP Sub Committee Chairman PART 1 - PERSONAL INFORMATION (If not relevant, insert N/A) Title Surname Forenames Margin to be used by referees to initial verification Present Grade of Membership (if any) Ordinary/TICorr/ MICorr/FICorr Membership Number Date of Joining The Institute of Corrosion Academic Qualifications (e.g. MSc, BSc, etc) Chartered Registrations (e.g. CEng/IEng/TEng) Memberships of other Professional or Learned Bodies Other Training/Certification e.g. NACE, TWI etc Gender Age Telephone Home Business Mobile Fax Home Business eMail Home Business Private Address (Including Postcode) Business Address (Including Postcode) Please indicate Sector/s Certification is to cover (delete as applicable) Underground and immersed metallic structures Yes/No Marine metallic structures; Yes/No Reinforced concrete structures; Yes/No Inner surfaces of metallic container structures. Yes/No It is essential that you provide full details of your knowledge and experience in each sector for which you are applying to be certificated. (See Section 3 and Appendix 1). PART 2 - EDUCATION AND TRAINING RECORD Institution attended Dates Subject studied Qualifications obtained Year awarded Margin to be used by referees to initial verification  Publications. Please list any publications that you have written below. Copies of papers, reports