MMD-CRF-01-05
CONFIDENTIAL REFERENCE FORM (to be accomplished by the Reference Engineer) Name of Applicant : ______________________________________________________________ (Please print) A. Do you know the candidate professionally? YES If YES, for how long? ________________years
(
)
NO
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)
What is your professional relationship with the candidate? _________________________________________________________________________ B. Has the candidate, to your knowledge, been in active professional practice for at least ten (10 ) years? YES ( ) NO ( ) How many years has he/ she been in the profession? _________________ C. Which significant achievement/s of the applicant are you familiar with? Please list below. 1. 2. 3. 4. 5.
6. 7. 8. 9. 10.
D. Please indicate whether you consider the candidate to be: ( (
) Well Qualified ) Qualified
( (
) Marginally Qualified ) Not Qualified
for the Grade of Senior Member. E. Name of the Reference Engineer : _____________________________________________ IIEE Membership Grade/ Year : ( ) Fellow : ( ) Senior : ( ) Regular : PRC License No. :
Year : ________________________________________ Year : ________________________________________ Year : ________________________________________ _____________________________________________
Business or Affiliation : ______________________________________________________ Address : ______________________________ Tel. No. : __________________________
________________________________________________ Signature & Printed Name