IEEE IIUM Student Branch - Membership Application

Cearfully fill in all sections in the form below to ensure the proper processing of your application.

Title:

First/Given Name:

Middle Name (Optional) :

Last/Family/Surname:

E-mail Address:

Phone Number:

Gender:
Male
Female

Date of Birth:

Address During Academic Year:
Address Line 1:
Address Line 2:
Address Line 3:
Addless Line 4:

Home/Permanant Address:
Address Line 1:
Address Line 2:
Address Line 3:
Addless Line 4:

Send All IEEE mails:
Address During Academic Year
Home/Permanent Address
Kulliyyah of Engineering Address

Current Degree Programme:
(e.g BSc Communications Engineering)

Expected Graduation Date:

Please send in your application fee of RM100.00 by contacting Ahmad Hafiz Yahya at 012 2206740 or any other IEEE IIUM committee Member.

Note: The payment of your application fee is needed to process this application, so send in your payment as soon as possible.