GRADUATE APPLICATION FORM / If you require assistance or advice please call Membership Services on +44 (0)1509678 152
or visit:
(Please write clearly in block capitals)
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)Qualifications
Start & Finish Dates / University/College / Degree/Diploma/Certificate
(e.g. MSc in Gas Engineering & Management) / Type
(e.g. FT/PT)
C)Engineering Experience (if you are in current employment or have previous experience, please give details)
Dates / Company Name / Job Title
Brief description of responsibilites
Brief description of responsibilities

IGEM INTERNAL USE ONLY:

Received Date: / Application Fee: / First Review Date: / Academic Qualifications Reference:
Training and Experience (years): / Notes: / Membership Committee Decision: / Membership Number:
D)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
E)Mentor Information (Please complete if applicable)
IGEM will make available mentors to all candidates who are seeking professional registration with EngC through the Institution, if required.
Do you have a Mentor? / No / If you would like IGEM to source a Mentor for you, please call +44 (0)1509 678152
Yes / (If yes, please complete details below)
Name of Mentor
Job Title
Contact Number/Email
EC Registration Number
EC Registation Grade / (Engineering Technician, Incorporated, Chartered)
F)Declaration by Applicant
I, the undersigned, hereby apply for election as/transfer to GRADUATE MEMBER 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
Data Protection
IGEM takes your privacy very seriously and we are committed to safeguarding and respecting your personal information. Your personal data is stored on our membership database and treated with the highest confidentiality in accordance with the IGEM privacy policy
G)Payment Details (Please mark boxes with an ‘X’)
Grade of Membership / Application Fee / X / Transfer Fee / X
Graduate Member / £30.00 / £20.00
Graduate Member - Concession (if you are applying within 1st year after graduation) / No Application Fee / No Transfer Fee
Grade of Membership / Annual Subscription Fee / X
Graduate Member / £119.00 or £109.00 (overseas members)
Graduate Member - Concession (if you are applying within 1st year after graduation) / £32.00
I wish to pay by:
Cheque (Please make payable to ‘IGEM’ and write your Name and Date of Birth on the reverse)
Debit/Credit Card (Please complete the payment section below)
Card No. / / / / / /
Expiry Date / / / 3 digit Security Code
Cardholders Name
H)Applicant Checklist(Please make sure you mark all boxes with an ‘X’)
a)All Sections of the application form have been completed
b)Provided IGEM with copies of certificates for all qualifications listed in section B
c)Completed payment details in Section G
d)Signature provided in Section F
If you have marked all the above boxes, you are ready to send your application to IGEM:

By Post to:By Email to:

Membership

IGEM

IGEM House

High Street

Kegworth

DerbyshireTelephone:

DE74 2DA+44 (0)1509 678152

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