Online ApplicationApplication No.: ( Pm5607 )

BOARD OF QUANTITY SURVEYORS MALAYSIA FORM A

QUANTITY SURVEYORS ACT 1967QUANTITY SURVEYORS RULES 1973

(Rule 17)

APPLICATION FORM FOR REGISTRATION AS AREGISTERED GRADUATE QUANTITY SURVEYOR

Full Name : NOR AZLIN BINTI ABDUL RAHIM

Date of Birth : 09/01/1985 Gender : Female

Nationality : Malaysian Place of Birth : KUALA LUMPUR

Race : Malay Identity Card No. : 850109146590

Home Address : NO. 25, JALAN SEKSYEN 3/13C, PEAK 208,TAMAN KAJANG UTAMA,43000 KAJANGSELANGOR

MALAYSIA

Postal Address : NO. 25, JALAN SEKSYEN 3/13C, PEAK 208,TAMAN KAJANG UTAMA,43000 KAJANGSELANGOR

MALAYSIA

Employer Name : PERUNDING NFL SDN BHD Office Address : WISMA PNFL, 8. JALAN BANGSAR UTAMA 9, BANGSAR UTAMA, 59000 KUALA LUMPURW.P. KUALA LUMPUR

MALAYSIA

House Tel. No. : 0123402810

Office Tel. No. : 03-2283 3503

Fax No. : 03-2282 6075

Hand-phone No. : 0123402810

Email : azlinrahim103@gmail.com

Academic Qualifications and dates obtained:

Name of School / Institute / College / University

Date of Admission

Date of Graduation

Qualification Achieved

MATRICULATION CENTRE OF

INTERNATIONAL ISLAMIC UNIVERSITY

MALAYSIA

01/06/2003 30/05/2004 MATRICULATION CERTIFICATE

UNIVERSITI ISLAM ANTARABANGSA

MALAYSIA (UIAM)

01/06/2004 23/08/2008 BACHELOR OF QUANTITY SURVEYING (HONOURS)

Professional Qualifications:

Pofessional Training (if appliable):

PENALTY

Section 24(a) of the Quantity Surveyors Act 1967: “Any person, firm or body corporate who procures or attempts to procure registration or approval or a certificate of registration or a permit to practise under this Act bt knowingly making or producing or causing to be made or produced any false or fraudulent declaration, certificate, permit, application or representation whether in writing or otherwise shall be guility of an offence under this Act and shall be liable on conviction to a fine not exceeding fifty thousand ringgit or to imprisonment for a term not exceeding three years or to both, and, in the case of a continuing offence, to a further fine of five hundred ringgit for each day during which the offence continues after conviction.”

DECLARATION TO BE SIGNED BY THE APPLICANT:

To

The Board of Quantity Surveyors Malaysia

I, the undersigned, apply for registration as a registered graduate Quantity Surveyor and declare as follows:-

I hold the above qualification(s) which I am requesting the Board to consider as being appropriate for registration as a registered graduate Quantity Surveyor.

I hereby agree to abide by the Quantity Surveyors Act 1967 and Quantity Surveyors Rules 1973, including the Code of Professional Conduct.

Fri, 20 Nov 2015 17:34:44 +0800 .....................................................

(Date) (Signature of Applicant)

NOTE :

Applicant must submit this form together with certified copies of certificates and other relevant documents in support of the application.

The application shall be accompanied with RM50.00 (processing fee) AND RM50.00(registration fee) in form of *money order/postal order/ bank draft/ cheque made payable to the "Lembaga Juruukur Bahan Malaysia."

If payment via CIMB Clicks, please submit the receipt together with this application form & the supporting documents.

FOR OFFICE USE ONLY

Date Received :

Date Tabled at Registration and Qualifications Committee Meeting :

Decision of Board :

Approved :

Rejected :

Deferred :

Reasons, if application is *Rehected/Deferred :

.....................................................................................................................................................................

.....................................................................................................................................................................

Date Applicant Notified :

Entered in Register :

Registration No :

Date Certificate of Registration Issued :