Please Type in the Boxes Provided, Or Write in Block Capitals

Please read the Membership Regulations, Code of Professional Conduct and Competency Framework found on the CIEEM website before completing this form.
Please ensure that:

all declarations have been signed;
copies of appropriate certificates/course content are enclosed with your application; and
payment has been authorised.

Failure to complete this form fully and accurately will delay admission. / OFFICE USE
Date received:
Payment Details:
Acknowledged:
Sponsor:
Missing details:
Notified of outcome:

Please type in the boxes provided, or write in block capitals.

PERSONAL DETAILS

Surname: / Forename(s): / Title:
Employer: / Position:
Home
Address: / Work
Address:
Postcode: / Postcode:
Home Email: / Work Email:
Home Tel: / Work Tel:
Which is your preferred contact address? (please tick) Home Work
How did you learn about CIEEM?

DETAILS OF HIGHER EDUCATION

This section must be completed fully; do not cross refer to a CV. A CV may be appended in addition.
Photocopies of all relevant qualifications, including degree certificates, must be appended to the application.

Please check thatyour degree course was accredited by CIEEM at the time you studied, otherwise you will need to complete the alternative Graduate membership application form available on our website.

Degree Course Title / Dates
(from – to) / Institution/Awarding Body / CIEEM Accredited Degree (Y/N) / Qualification and Classification

RESEARCH AND PUBLICATIONS RECORD

Please continue on a separate sheet if necessary, or incorporate with your CV.

MEMBERSHIP OF PROFESSIONAL BODIES AND LEARNED SOCIETIES

Please list all Professional Bodies and Learned Societies of which you are a member.

Professional body / Membership category
(if relevant) / Date accepted into this category

DETAILS OF CURRENT PROFESSIONAL ACTIVITY

Current Employment Status
(e.g. Self-employed, employed, volunteer)
Position / Full/Part time?
Employer / CommencementDate
Description of current professional role(s)
1. Please indicate grade or seniority level held.
2. Describe the main purpose or scope of the role.
3. Give details of some relevant tasks or projects undertaken.

PREVIOUS RELEVANT EXPERIENCE

Summary of all previous relevant projects/appointments (including periods of voluntary work, work undertaken whilst self-employed and previous posts with a current or previous employer if relevant). If you don’t have any previous relevant experience please leave this section blank.If you wish to attach a CV in support of your application please append.

Begin with the most recent.
Dates (month/year) must be given.
Part time (PT) work must be detailed in full (i.e. number of days per week and/or month).

Start date / End date / Employer, Organisation or Client / Role / Permanent FT/PT or contract (see 3 above) / Paid/
Unpaid / Actual time in role / Relevant duties and/or experience (including projects, responsibilities)

CONTINUING PROFESSIONAL DEVELOPMENT (CPD)

Please describe any relevant training or Continuing Professional Development undertaken, e.g. courses organised by CIEEM, external training providers or by your employer.

Date of activity / No of
hours / Title & Description of CPD activity / Provider / Structured or unstructured
(S or U/S) / Knowledge area or skill developed and how it has been applied to your professional practice (max 100 words)

SPONSOR

One sponsor is required to support your application and the accuracy of the information contained within it. Your sponsor should preferably be a member of CIEEM but if this is not possible he/she should be a member of a similar professional body, a professional colleague or an academic member of staff.

In all cases sponsors must have knowledge of your work and be able to endorse your competence and integrity as a potential member of the Chartered Institute. Sponsors may be in breach of the Chartered Institute’s Code of Professional Conduct (or that of another professional body of which they are a member) if they knowingly endorse false competence claims. In the interests of clarity, further information may occasionally be sought from sponsors.

All documentation along with detailed guidance for sponsors can be found online here >

Note to sponsors:

As a sponsor of this applicant you are asked to confirm that:

a)you have read the Code of Professional Conduct and the Membership Regulations;

b)you consider the applicant to be a person of integrity and that he/she is suitable for election to the grade of Graduate membership;

c)to the best of your knowledge the applicant has practised, currently practises and is likely to continue to practise in a manner which accords with the principles and objectives of the Chartered Institute’s Code of Professional Conduct; and

d)to the best of your knowledge all the information contained in the application is accurate.

Whilst we prefer a signed hard copy of the sponsor form, we understand this is not always possible. Scanned or electronic signatures will be accepted, however, to enable the application to be processed, we will confirm your sponsorship of the applicant for Graduate membership via your personal email account.

Name:
Position:
Capacity in which you know the applicant: (e.g. colleague, manager)
Qualifications/ professional memberships: (e.g. BSc, MSc, CEnv, CEcol, MCIEEM)
Address:
Postcode:
Email:
Tel:
I confirm points (a) – (d) above and consider that to the best of my knowledge the applicant fulfils the Chartered Institute’s conditions for Graduate membership.
Signed: / Date:
Sponsor’s statement (max. 1,000 words)
Please state why you consider the applicant suitable for Graduate membership of CIEEM.
OFFICE USE
Sponsor approved: / Comments requested: / Comments received:

DECLARATION BY APPLICANT

By entering my name in the box below, I certify that the information in this application to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my application for Membership subject to approval by the Governing Body of the Chartered Institute of Ecology and Environmental Management (CIEEM).
I agree that details pertinent to my application and membership history will be held and used by CIEEM, under the terms of the Data Protection Act 1998, for the purposes of establishing and maintaining membership of, or support for, CIEEM or providing and administering activities for members.
I confirm that I have read and agree to be bound by the terms and conditions of membership stated in the Membership Regulations or any subsequent amendments thereof. I confirm that I have read and agree to be bound by the Code of Professional Conduct or any subsequent amendments thereof.
I understand that my application for membership may be refused,or my membership may be later withdrawn, if I have provided false or untrue information or if I am found not to have complied with the Membership Regulations or Code of Professional Conduct.
Signed: Date:

PAYMENT INFORMATION

Initial payment* / Future payments
£72.00* – UK, Ireland and international / £60.00 – UK, Ireland and International

* This initial payment includes a £12.00 (inc. VAT) administration fee

Please note that:

Your initial payment may be made by cheque or debit/credit card, but cannot be paid by Direct Debit in the first year.
Members admitted in July, August or September, are entitled to membership until 30th September of the following year. All subsequent subscriptions are payable annually on 1st October.
Payment will be processed and your application acknowledged upon receipt.
Any charges incurred by CIEEM due to declined cheque payments will be your responsibility.
Receipts for subscriptions and any appropriate refunds are provided at the time of admission to the Chartered Institute.
When the Membership Admissions Committee has considered your application appropriate refunds are provided if the grade offered is different from that for which you applied.

Please tick one box and complete details as appropriate:

I enclose a cheque, payable to CIEEM for the amount of: £72.00
I wish to pay by debit/credit card, please charge to my account the amount of: £72.00
Card number: / Start date: / End date:
Name on Card: / Issue number: / Security no:
Address of cardholder:
Signature: / Date:
Please invoice for the amount of £72.00
Employer’s name:
Invoice address:
Invoice Postcode:
Invoicingdetails
(e.g. purchase order no):

APPLICATIONCHECKLIST

Please tick the boxes below to confirm that:

You have signed the declaration and dated this application
Your sponsor has signed and dated this application
You have enclosed photocopies of your degree certificates
You have included a transcript or list of your degree modules
You have included the correct payment or authorisation
You have checked your application thoroughly e.g. spell check

Please note: Applications will normally be processed within SIX WEEKS butFailure to complete this form adequately will delay admission.

Please post this form to:

CIEEM, 43 Southgate Street, Winchester, Hampshire SO23 9EH

Or email it to

04/2017