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org

2010 Membership Application

Select Your Membership Option


Individual Membership
Student Membership

PART 1

(Students must enclose proof of


current enrollment. Do not send
separately. Student membership
enrollments are subject to audit).

By joining PMI, you agree to adhere to the Project Management Institute Code of Ethics and Professional Conduct.
The Code can be viewed by visiting www.PMI.org.
Please type or print clearly.

10
09
Date ______/
______/
2010

Have you previously been a member of PMI?


No

Yes

Year of last membership

If yes, what was your previous ID#?

JALILUL

MR.
PREFIX (MR., MRS., MS., DR.)

REHMAN

KHAN

FIRST NAME (Maximum of 20 letters)_ MI

LAST NAME (Maximum of 20 letters)

SUFFIX

JALILUL REHMAN KHAN


PLEASE PRINT NAME AS YOU WANT IT TO APPEAR ON YOUR MEMBERSHIP CERTIFICATE

SENIOR MANAGER ELECTRICAL DESIGN


JOB TITLE

COMPANY/ORGANIZATION

ALLIGATOR DESIGNS PVT LTD

Business Address
STREET ADDRESS (LINE 1)

2nd FLOOR, C BLOCK, KUSHALl GARDEN ARCADE,

STREET ADDRESS (LINE 1)

1A, 2nd PHASE, PEENYA INDUSTRIAL AREA,

CITY
BANGALORE

STATE/PROVINCE
KR

ZIP/POSTAL CODE


560047

COUNTRY

INDIA

Home Address
STREET ADDRESS (LINE 1)

75/1, 2nd FLOOR, 5th CROSS, ROSE GARDEN, NEEL SANDRA

STREET ADDRESS (LINE 1)

BEHIND SHANTI NIKETAN SCHOOL, VIVEK NAGAR PO

CITY
BANGALORE

STATE/PROVINCE KR

ZIP/POSTAL CODE


560047

COUNTRY
INDIA

Contact Information
PRIMARY E-MAIL


jrkhan@alligatordesigns.com

BUSINESS PHONE

(WITH COUNTRY CODE, AREA CODE AND EXT.)

HOME PHONE

(WITH COUNTRY CODE AND AREA CODE)

+91 80 25710215

SECONDARY E-MAIL
FAX

+91 80 41172390
MOBILE PHONE

(WITH COUNTRY CODE AND AREA CODE)

+919980088146

khanjrkhan@gmail.com

(WITH COUNTRY CODE AND AREA CODE)

TOLL-FREE PHONE

By supplying the fax information above, you consent to being contacted by PMI at the fax number provided.

General Information

4.5 Years

IS PROJECT MANAGEMENT YOUR PRIMARY PROFESSION?

Yes

I would like to:

What is your preferred mailing address? Home

Business

What is your preferred renewal billing address? Home

HOW MANY YEARS HAVE YOU BEEN PRACTICING PROJECT MANAGEMENT?

Receive promotional messages from PMI about PMI products, services, and events

No

Business

Be included in 3rd party postal mailing lists

Your New Member Kit will be mailed to you.

Please Complete Part 2

2010 Membership Application

PART 2

Join PMI online using a credit card @ PMI.org


Your Name

DUES INFORMATION: One full year membership

What is your organizations


primary business activity
(industry)?

(050)
(049)
(019)
(020)
(052)
(021)
(047)
(022)

Construction
(002) Commercial/Heavy Industrial
(001) Residential
(003) Other________________

Resources
(023)
(027)
(025)
(024)
(026)

Agriculture
Coal/Gas/Oil
Ferrous Mining
Forestry
Non-Ferrous Mining

Manufacturing

(028) Automotive
(029) Chemical
(030) Concrete/Clay/Glass/Stone
(031) Electrical/Electronic
(032) Food
(033) Machinery/Metals
(034) Paper
(035) Petroleum
(040) Pharmaceutical
(036) Plastics
(037) Textiles/Fabrics
(038) Wood
(039) Other________________

What category best describes


your job function?
Engineering

(157)
(151)
(152)
(153)
(154)
(155)
(156)
(150)

Chemical
Civil
Electrical
Electronics
Environmental
Industrial
Mechanical
Other____________

Management

Other Business Activities

(045) Academia
(004) Aerospace
(005) Architecture/Design
(006) Arts/Entertainment/
Broadcasting
(046) Automation Systems
(007) Business Mgmt Svcs./
Mgmt Consulting
(053) City Management
(008) Computers/Software/DP
(044) Consulting
(009) Defense
(048) E-business
(010) Economics/Finance
(011) Education/Training
(041) Engineering
(012) Environmental/Waste/Sewage
(042) Financial Services
(013) Health/Human/
Social Services
(043) Information Technology
(051) International Development
(014) Legal
(015) Printing/Publishing
(016) Public Administration/
Government
(017) Real Estate/Insurance
(018) Recreation

Supply Chain
Systems Security
Telecommunications
Transportation
Urban Development
Utilities
Web Technology
Other________________

(102) Communications
(149) Configuration
(104) Contract/Procurement
(101) Corporate/Administrative
(105) Cost
(148) Critical Chain
(147) Earned Value
(108) Human Resources
(109) Information/Computer
(112) Materials
(114) Project/Program
(117) Quality
(118) Records
(120) Risk/Safety
(121) Scope/Technical
(122) Site/Facility
(124) Time Mgmt/Scheduling/
Planning

Other

(103) Consulting
(106) Distribution
(107) Finance
(127) Financial Services
(110) Legal
(111) Marketing/Business
Development/Sales
(113) Production
(115) Project Accounting/Audit
(116) Public Relations
(119) Research/Product
Development
(056) Retail
(128) Service & Outsourcing
(123) Teaching/Training
(146) Web Strategist/Technologist
(125) Other_________________

Return Completed Form with Payment to:


Project Management Institute, 14 Campus Boulevard
Newtown Square, Pennsylvania 19073-3299 USA
Or fax to: 1 610 819 0746
EMEA Applicants Return Completed Form with Euro or U.S. Dollar Payment to:
Project Management Institute, EMEA Service Centre
300, Avenue de Tervueren B-1150 Brussels, Belgium
Or fax to: +32 2 743 15 50
Asia Pacific Applicants Return Completed Form with U.S. Dollar Payment to:
Project Management Institute, Asia Pacific Service Centre
73 Bukit Timah Road, #04-01 Rex House Singapore 229832
Or fax to: +65 6336 6449

Amounts in U.S. dollar and euro.

U.S.dollar

euro

$ 119.00

100.00

OPTION 1 PMI Individual Membership


PMI Individual Member Dues

OPTION 2 PMI Student Membership


$ 30.00* 25.00*

PMI Student Member Dues


*MUST ATTACH verification of current enrollment in
a degree-granting program. PMI will not process
your membership without this documentation.
Do not send separately.

Dues Calculation
Membership Dues (Enter amount from option 1, or 2 above)
Application Fee

$_____.__
119 00 _____.__
$ 10.00

10.00

(Applies to New and Rejoining Members)

Component Fees (Visit www.PMI.org for component list and fees)


PMI Chapter Name(s)___________________________ $_____.__

_____.__

PMI Community Name(s) _______________________ $_____.__

_____.__

Optional Air Mail $60.00/ 50.00

$_____.__

_____.__

Optional Donation to the PMI Educational Foundation


If applicable, calculate Canadian Tax (see below)

$_____.__

_____.__

$_____.__

_____.__

Total Amount Enclosed

129 00 _____.__
$_____.__

(for PMI publication mailing outside North America)

METHOD OF PAYMENT:
Payment must accompany application. Purchase Orders not accepted.
o W
 e accept cheques made payable to PMI in euro or U.S. dollars drawn on
a U.S. bank, bank transfers or the following credit cards:
VISA

MasterCard

American Express

Diners Club

Discover

Card Number _____________________________________________


(MM) /_______
(YY)
Exp. Date _______

Signature ________________________________________________

Do not send cash.


Please remit total payment in one currency, U.S. dollar or euro.
PMI is an individual membership organization. All membership fees are
nonrefundable, nontransferable and subject to change.

CANADIANTAXINFORMATION
In accordance with Canadian tax law, taxes are collected on member dues and application fees
relating to PMI and the following chapters: Canadas Technology Triangle (CTT); Lakeshore;
Durham Highlands; New Brunswick; Levis; Manitoba; Montreal; Northern Alberta;
Nova Scotia; Ottawa Valley; Regina/ S. Saskatchewan; South Western Ontario; Southern
Alberta, and Southern Ontario. Canadian residents should include applicable taxes in the space
provided. The rate of tax charged varies depending upon the province address you use.
Tax calculations by province are 15% for Nova Scotia; 13% for New Brunswick, Newfoundland/
Labrador and Ontario; 12.88% for Quebec; 12% for British Columbia; 5% for all other
provinces. If your employer is paying for your membership and has been granted tax-exempt
status by the appropriate Canadian authorities, you will not be able to submit your application
on-line. You will need to mail or fax your membership application along with a tax-exempt
certification meeting the specifications of the Canadian government.
GST/HST Registration #:897944807RT0001 QST Registration #:1202723001TQ0001
2010 Project Management Institute, Inc. All rights reserved.
PMI, the PMI logo, PM Network, and PMI Today are registered marks of Project Management Institute, Inc.
064-001-2010

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