If You Have Fully Completed the Application Form, You Are Ready to Send Your Application

ENGINEERING ASSOCIATE APPLICATION FORM / If you require assistance or advice please call Membership Services on +44 (0)1509 678 152
or visit: www.igem.org.uk/membership/grades.asp
(Please write clearly)
A)  Contact Details
Title / Business Address
Surname
Forename
Other Names / (B) Tel. No. / Post Code
Date of Birth / Home Address
Gender
Mobile No.
Email address / (H) Tel. No. / Post Code
Present Grade of Membership & Membership No. / Which address do you wish IGEM to use for mailing?
(if applicable) / Business / Home
B)  Present Employment (Further information may be given on separate sheets if necessary)
Dates / Company Name / Job Title
Brief description of duties
C)  Qualifications (If held)
Start & Finish Dates / College/Academic Institution / Degree/Diploma/Certificate/NVQ
(e.g. Diploma in Project Management or
BSc in Mathematics) / Type
(e.g. FT/PT)
D)  Declaration by Applicant
I, the undersigned, hereby apply for election as/transfer to ENGINEERING ASSOCIATE of the Institution of Gas Engineers & Managers and certify that the statements contained herein are true. If elected/transferred, I will observe the relevant By-laws, Regulations and Code of Conduct.
Signature of Applicant / Date
IGEM INTERNAL USE ONLY:
Received Date: / Application Fee: / First Review Date: / Membership Committee Decision:
Data Protection
IGEM is licensed under the Data Protection Act to hold the data you provide solely for purposes of maintaining your membership and to provide you with appropriate benefits. As a service to you, we will send you information regarding IGEM events, services and products that may be of professional interest to you. Your information will also be given to your Section representative who may contact you regarding events in your area. If you would prefer not to receive emails from IGEM please tick this box
E)  How did you hear about IGEM? (Please mark boxes with an ‘X’)
Employer / University / College / IGEM Event
IGEM Website / Member Recommendation / Publication/Magazine
Trade Show / Word of mouth / Other
F)  Payment Details (Please mark boxes with an ‘X’)
Grade of Membership / Application Fee / Transfer Fee / Subscription Fee
Associate / £30.00 / £20.00 / Please refer to current fee sheet
PLEASE NOTE: Membership Subscription Fees are issued on a pro rata basis from the 1st July annually. For further clarification on the fees due, please contact Membership Services.
I wish to pay by:
Debit/Credit Card (Please complete the payment section below)
Cheque (Please make payable to ‘IGEM’ and write your Name and Date of Birth on the reverse)
Card No. / / / / / /
Expiry Date / / / 3 digit Security Code
Cardholders Name

If you have fully completed the application form, you are ready to send your application to IGEM:

By Post to: By Email to:

Membership Services

IGEM

IGEM House

High Street

Kegworth

Derbyshire Telephone:

DE74 2DA +44 (0)1509 678152

P/07/11–V2 Form - EA