PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC.

PARTICIPANT REGIONAL ELIMINATION

Region _________

Venue :_____________________________________________________

Host

2 x 2
: ____________________________________________________
PHOTO

Name ___________________________________________________________________________________________________________
(Surname)
(First Name)
(Middle Initial)
School Chapter _________________________________________________________________________________________________
Address _________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Current Year _____________________________________________________________________________________________________
Position in School Chapter ______________________________________________________________________________________
School Contact Tel. No. __________________________________________ Fax No. _____________________________________
School E-mail address ___________________________________________________________________________________________

PERSONAL DATA:
Home Address ___________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Tel. No. _____________________________________________ Fax No. ____________________________________________________
Cell Phone _________________________________________ E-mail address _____________________________________________

I certify that I am currently enrolled and is a bonafide student member of PICE in good standing and have
not participated in any Regional Elimination Competition this year.
Photocopy of valid school identification
Photocopy of school registration

___________________________________
Signature
Date _____________________________

Note: This form should be fully accomplished

and submitted to the PICE National office at
least five (5) days before the Regional
Elimination.