DIVISION I EDUCATION – List in chronological order the name and location of each college or university from which you have earned a degree; also list other appropriate training. Name & Location Years Date Degree Field In Which Of Institution From - To Graduated Received Degree Was Issued DIVISION II PROFESSIONAL REGISTRATION – I am a Professional Engineer: yes no I am a Registered Architect: yes no I am an Engineer in Training (E.I.T.): yes no I am a Certified Plant Engineer: yes no I am an Energy Auditor: yes no If yes to any of the above, complete the following and enclose copy of registration. Registration must indicate that license is currently in force. Country Registration No. Date Now in Force yes no yes no yes no yes no yes no Have any registrations been revoked or suspended? yes no If yes, please explain: DIVISION III – EXPERIENCE RECORD Please complete the following in chronological order and list the most recent employer first. Include a description of job functions held for those periods of employment, which qualify you for specific category of certification as applied for. This form may be copied if additional space is needed. Date: Employer CONCISE STATEMENT OF ENERGY-RELATED WORK PERFORMED From-To(mm/yy mm/yy) Name & Address –
DIVISION I – EDUCATION List in chronological order the name and location of each college or university from which you have earned a degree; also list other appropriate training. Name & Location Of Institution Years From - To Date Graduated Degree Received Field In Which Degree Was Issued DIVISION II – PROFESSIONAL REGISTRATION I am a Professional Engineer: yes no I am a Registered Architect: yes no I am an Engineer in Training (E.I.T.): yes no I am a Certified Plant Engineer: yes no I am an Energy Auditor: yes no If yes to any of the above, complete the following and enclose copy of registration. Registration must indicate that license is currently in force. Country Registration No. Date Now in Force yes no yes no yes no yes no yes no Have any registrations been revoked or suspended? yes no If yes, please explain: DIVISION III – EXPERIENCE RECORD Please complete the following in chronological order and list the most recent employer first. Include a description of job functions held for those periods of employment, which qualify you for specific category of certification as applied for. This form may be copied if additional space is needed. Date: From-To(mm/yy – mm/yy) Employer Name & Address CONCISE STATEMENT OF ENERGY-RELATED WORK PERFORMED
CEM-Applicationjul2018_0.docx