CERTIFICATE OF EXPERT PRACTICE IN

LEADERSHIP AND MANAGEMENT 2018

APPLICATION FORM

All sections must be legibly completed. Illegible or incomplete application forms will be rejected and returned.

IBMS Membership Number: ______

Title Surname: Forename:

Address for all correspondence including examination results:

Email: (please print clearly)

Date of Birth: (DD/MM/YY)

Telephone No: ______Mobile No: ______

Employment address if different from above:

Email:

Telephone No: ______Mobile No: ______

Declaration

If an applicant subsequently gains the Institute’s Certificate of Expert Practice in Leadership and Management on the basis of incorrect information, this may give them a pecuniary advantage by deception. In such circumstances the Institute may withdraw the Certificate. The onus for ensuring the full and accurate disclosure of information rests with the applicant.

·  I declare that the information given in this document and in all attached forms is true and accurate.

·  I understand that failure to disclose full information or any deliberate misrepresentation of information can be a serious matter and will invalidate my application.

Signature of Applicant: Date:

Signature of Manager: Date:

Payment Details

Membership Number

Cheque

I enclose a cheque for the assessment fee of £650.

Please note cheques should be made payable to the Institute of Biomedical Science

Purchase Order

Please invoice my employer

Purchase Order No: ______

(Please note the actual purchase order must be provided rather than just the number)

Card Payments

I wish to pay by credit/ debit card

For security reasons rather than providing the card details on this form we will contact you at your correspondence address on receipt of this form to get these details.

Completed forms together with the examination fee of £650 to be submitted to:

Head of Examinations

Institute of Biomedical Science

12 Coldbath Square

London
EC1R 5HL

Please note: Places for the course will be allocated strictly on the basis of the order in which completed applications forms (WITH payment of the course fee) arrive at Coldbath Square.