APPENDIX 1:

FORM A/ VER1/27FEB2007
EIA CONSULTANT REGISTRATION SCHEME
REGISTRATION FORM

SECTION A – PERSONAL INFORMATION

Category of
registration(Please tick EIA Consultant Subject Consultant
in shaded box).
Note : If you wish to
apply as EIA
Consultant and Subject Assistant Consultant
Specialist, please tick
both boxes
If registered under previous
registration scheme, kindly indicate
your registration number
Full Name
Title (Prof, Dr, Mr., Mrs., Ms)
Identity card number (Malaysian - -
only)
Date of birth
Passport number (Foreigners only)
Organization
Job Title

HOME Address: Recent

Photo
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
Postcode ……………… Country …………………………………….. For DOE use only

WORK/ OFFICE Address :

……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
Postcode …………………Country ……………………………………..
Which address would you like us to use : Home Work
All future correspondence will be sent to the address indicated.

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Contact Information :

Telephone (Work) : ………………………..… E mail : …………………………………

Fax (Work) : …………………………. Handphone : ……………………………

How would you like to receive general correspondence? E-mail Mail

Area of expertise
Note :

(i) Applicant for EIA Consultant and EIA Assistant category may select up to four fields
from the list of areas of expertise. You may also indicate other relevant field that is not in
the list. Mandatory interview will be conducted for applicants aplying for more than four
fields.
(ii) Subject specialist may only choose one field

(i)

(ii)

(iii)

(iv)

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Further explanation on your expertise (optional)

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SECTION B : ACADEMIC QUALIFICATIONS

Course
Date t
Date Full or i Course Description of subject areas
complete Award/grade
Started part time t provider studied
d
l
e

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 *Please ensure copies of certificates are enclosed and please use attachments if this space is inadequate

SECTION C : WORKING EXPERIENCE

Dates &
duration Organization Job title Responsibilities Verification Source – name,
company, address,
tel, fax, email/
letter of
appointment/paysli
p

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SECTION D : MEMBERSHIP OF PROFESSIONAL BODIES

Official Current Data Current

Level Description of Relevant
Professional Body Abbreviati Membership
Achie Training/Exams
on Level
ved

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*Please ensure certified copies of certificates are enclosed

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SECTION E : RELEVANT TRAINING/COURSES

Title of Course/
Date Detail
Date course/ s of Details for verification –
Course/Training course/
training On Subjects covered name, address,
Provider training
completed site tel, fax and e mail
started
Traini
ng

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*Please ensure certified copies of certificates are enclosed

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SECTION F : RELEVANT EIA EXPERIENCE

Dates & Title of EIA Report Responsibilities & brief

duration of description of work Verification Source –
study name, company,
address, tel, fax,
email

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SECTION G : OTHER ENVIRONMENTAL MANAGEMENT EXPERIENCE

Dates & Description of work (please Job title held

duration of provide a 2-3 sentence summary Responsibilitie Verification Source – name,
s company, address,
study of the work undertaken tel, fax, email

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SECTION H : DECLARATION
I hereby apply for registration and agree to observe and abide by the
Code of Practice specified in the final part of this form. I certify that the
statements contained in this form are correct to the best of my knowledge
and belief.

Signature : Date :

References
1 2
Name:…………………………………….. Name:……………………………………..

Address: Address:
…………………………………………… ……………………………………………
…………………………………………… ……………………………………………
………………… …………………………………
Tel:…………………Fax:……………….. Tel:…………………Fax:………………..
E-mail:……………………………………. E-mail:…………………………………….
(Form B : Referee Assessment (Appendix 4) must be
submitted to the referees. Referees must submit the
completed form directly to DOE).

CODE OF PRACTICE

All EIA Consultants and EIA Assistants are obliged to improve the
standing of the environmental impact assessment profession by
rigorously observing the following Codes of Practice. Failure to
conform may result in suspension or deregistration. All registrants
shall:
Act professionally, accurately and in an unbiased manner;
Strive to increase the competence and prestige of the
environmental impact assessment profession;
Assist those under my supervision (if relevant) in developing their
management, professional and environmental impact assessment
skills;
Not to undertake any job that I am not competent to perform;
Not to represent conflicting or competing interests and to disclose
to any client or employer any relationship that may influence my
judgment;
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 Not to accept any inducement, commission, gift or any other
benefit from any interested party or knowingly allow colleagues to
do so;
Not to intentionally communicate false or misleading information
that may compromise the integrity of any EIA study; and
Not to act in any way that would prejudice the reputation of the
EIA Consultants Registration Scheme or the environmental
consultants registration process and to co-operate fully with any
inquiry in the event of any illegal breach of this code.

Please return to the completed form to :

Secretariat
EIA Consultants Registration Scheme
Assessment Division
Department of Environment
Ministry of Natural Resources and Environment
Level 1-4, Podium Block 2&3
Lot 4G3, Precinct 4
Federal Government Administrative Centre
62574 Putrajaya.
Tel : 03-88712000 Fax : 03-88891045
Web: www.doe.gov.my

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