| 1.0 PERSONAL DETAILS |
| NIQS MEMBERSHIP NUMBER: | P00254N | | SURNAME: | NWORIE | | OTHER NAMES: | SAMPSON COLLENIUS | | TITLE/GENDER: | MR /MALE | | DATE OF BIRTH: | 1992-08-08 | | CHAPTER: | EBONYI | | PHONE NUMBER: | 08166566995, | | EMAIL ADDRESS: | sampsoncollenius@gmail.com | | POSTAL ADDRESS: | ITEM AMAGU IKWO LGA, EBONYI STATE | | CURRENT MEMBERSHIP GRADE: | PROBATIONER | | DATE OF REGISTRATION: | 2024-01-18 | | DIET: | MARCH, 2026 | | DISABILITY: | NO |
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| 2.0 PREFERRED INTERVIEW CENTRE: |
| ABUJA |
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| 3.0 O' LEVEL SUBJECTS RESULT (5 CREDITS FROM WAEC/NECO/NABTEB): |
| SUBJECTS | GRADE | | ENGLISH | C5 | | MATHEMATICS | C6 | | PHYSICS | C6 | | CHEMISTRY | C4 | | BIOLOGY | C5 |
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| 4.0 EDUCATION: |
| SN | UNIVERSITY/INSTITUTION | COUNTRY | DEGREE/DIPLOMA NAME
(eg. B.Tech Quantity Surveying) | DATE COMPLETED | | 1 | AKANU IBIAM FEDERAL POLYTECHNIC, UNWANA AFIKPO, EBONYI STATE | NIGERIA | ND IN QUANTITY SURVEYING | 2013-09-10 | | 2 | AKANU IBIAM FEDERAL POLYTECHNIC, UNWANA AFIKPO, EBONYI STATE | NIGERIA | HND IN QUANTITY SURVEYING | 2016-09-30 |
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| 5.0 MEMBERSHIP OF ANY OTHER PROFESSIONAL INSTITUTION(S): (IF ANY) |
| SN | NAME OF INSTITUTION | CURRENT GRADE | HOW MEMBERSHIP WAS ACHIEVED
(E.G. EXAMINATION) | YEAR REGISTERED/
OBTAINED/ELECTED |
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| 6.0 PATICULARS OF TPC EXAMINATION AND LOGBOOK/DIARY STAGE 3 PASSED (OR RICS MEMBERSHIP) |
| DETAILS | YEAR/MONTH | EXAM. NO.
(WHERE APPLICABLE) | CENTER
(WHERE APPLICABLE) | | TPC EXAMINATION | MAY 2025 | TPC/2025/03/77 | ENUGU | | LOGBOOK/DIARY STAGE 3 | FEBRUARY 2026 | | |
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| 7.0 PROFESSIONAL EXPERIENCE: |
| SN | EMPLOYER'S NAME AND ADDRESS | POSITION HELD & DATES | DUTIES | | 1 | MINISTRY OF PROJECT MONITORING AND EVALUATION, ABAKALIKI, EBONYI STATE | QUANTITY SURVEYOR (2021-02-01 - Date) | MEASUREMENT OF BUILDING WORKS, CIVIL ENGINEERING WORKS AND MEP, PREPARATION OF INTERIM VALUATION, PROJECT MANAGEMENT |
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| 8.0 EMPLOYER DETAILS |
| a) NAME OF EMPLOYER: | MINISTRY OF PROJECT MONITORING AND EVALUATION, ABAKALIKI, EBONYI STATE | | b) EMPLOYER'S BUSINESS ADDRESS: | STATE SECRETARIATE, OCHUDO CENTENARY CITY, ABAKALIKI, EBONYI STATE | | c) NATURE OF EMPLOYER'S BUSINESS: | MDA | | d) POSITION OF APPLICANT: | QUANTITY SURVEYOR (QS) | | e) DATE OF EMPLOYMENT: | 2021-02-01 |
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| f) I hereby attest that to the best of my knowledge, the particulars given by me and the applicant here are true and correct. |
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EMPLOYER'S SIGNATURE & DATE |
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| 9.0 SPONSOR DETAILS |
| a) SPONSOR'S NIQS MEMBERSHIP NUMBER: | 05668 | | b) SPONSOR'S FULL NAME: | EZE CLINTON OGBONNIA | | c) SPONSOR'S EMAIL ADDRESS: | EZECLINTON12@GMAIL.COM | | d) SPONSOR'S CONTACT ADDRESS: | 1 IFITEDUNU STREET ABAKALIKI EBONYI STATE | | e) SPONSOR'S MEMBERSHIP GRADE: | MEMBER | | f) SPONSOR'S RESGISTRATION DATE:: | 2023-08-08 |
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| g) I hereby declare that to the best of my knowledge, the particulars given by me and the applicant here are true and correct. |
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SPONSOR'S SIGNATURE & DATE |
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| 10.0 APPLICANT'S DECLARATION |
I declare that the particulars given on this form are true and correct and that I will abide by the Rules and Regulations governing the Institute’s Examinations.
By completing and submitting this application form, you agree to be bound by all existing NIQS Examination Policies, Rules and Guidelines and the rules guiding the MARCH, 2026 professional examination in particular.
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| Applicant's Signature.......................................................................... Date.............................................. |
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| 11.0 STATE CHAPTER CHAIRMAN/SECRETARY (COMPULSORY) TO BE COMPLETED MANUALLY |
| CHAPTER: | EBONYI
| | NAME: |
| | NIQS MEMBERSHIP NUMBER: |
| | DESIGNATION: |
| | PHONE NUMBER: |
| | DATE: |
| | EMAIL: |
| | SIGNATURE: |
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PC6