Form Ex41 (Fellows only)
This form is only to be used by those
who are already Fellows of the Society
APPLICATION TO REGISTER FOR EXAMINATIONS IN 2016
Please use BLOCK CAPITALS
SURNAME Mr/Mrs/Ms/Miss/Dr/ ……………………………………………………OTHER NAMES (in full) ……………………..…………………………………………
ADDRESS……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
POST / ZIP CODE …………………..………
Telephone ………………………………
Email ………………………………………………………………………………
Please state your name EXACTLY as you wish it to appear on any Results Notices or Certificates (note: titles (Mr, Mrs, Ms, Miss, Dr, etc) are not used)
……………………………………………………………………………………
I have read and I understand the information in the general Guide to Examinations.
I apply to register for the following examinations to be held in 2015 (please tick appropriate 6box(es))
Ordinary Certificate (2 papers)Module 1
Module 2
Higher Certificate
Module 1
Module 2
Module 3
Module 4
Module 5
Module 6
Module 7
Module 8
Graduate Diploma
Module 1
Module 2
Module 3
Module 4
Module 5
Continued on next page
Signed …………………………………….Date ……………………………….
If you have previously registered for any level of the Society's examinations, please give your candidate number (if known):
…………………………..
FEES
The fee for registration is as follows.
Examinations to be taken
/ UK / Overseas *Ordinary Certificate
1 module / £84 / £94
2 modules / £168 / £188
Higher Certificate
1 module / £56 / £66
2 modules / £112 / £132
3 modules / £168 / £198
4 modules / £224 / £264
5 modules / £280 / £330
6 modules / £336 / £396
7 modules / £392 / £462
8 modules / £448 / £528
Graduate Diploma
1 module / £90 / £105
2 modules / £180 / £210
3 modules / £270 / £315
4 modules / £360 / £420
5 modules / £450 / £525
* Candidates in countries recognised by the Society as "Economically Developing Areas" pay at the UK rates. Candidates who wish to claim these rates must check with the Society in advance whether their countries are so recognised.
See next page for methods of payment
All payments should be payable to The Royal Statistical Society.
Payment in the UK may be made by cheque, credit card (see below) or postal order. Payment from abroad may be made by sterling cheque drawn on a sterling currency account, sterling bank draft, credit card, postal order or international money order.
Credit card payment
I wish to pay by credit card (Visa/MasterCard/Maestro/American Express).
Please charge my account. My card number is:
Security code (For Visa/MasterCard/Maestro – last 3 digits of the number printed on signature strip on back. For AMEX – 4 digit code on front of card):
Signature:Valid from …….. / ………Expiry date …….. / ………
Name (on credit card):Billing Address used by credit card company, if different from address on page 1 (mustinclude postcode):
Payment via Invoice/Purchase Order
Please invoice me/my employer as follows:
Company name:For the attention of:
Invoice address:
E-mail address:
Purchase order number:
Continued on next page
This form must be returned by postor e-mailwith the correct remittance to
Professional Affairs and Examinations Manager
The Royal Statistical Society
12 Errol Street
London
EC1Y 8LX
UK
The opening date for registration for the 2016 examinations is 1 October 2015.
The closing date is 1 March 2016.
Late entries will not be accepted. [But see page 10 of the general Guide to Examinations (Ex1).]
Your attention is drawn to the information in the general Guide to Examinations (Ex1) concerning withdrawal from the examinations.
The Society's telephone and fax numbers are
phone :020 7614 3915
fax :020 7614 3905
(for callers from overseas, the leading 0 is replaced by the international dialling code for the UK, usually +44).
The email address for all examinations matters is
______
The information given on this form will be used by the Royal Statistical Society to process your application. If successful it will be retained and used by staff, officers and members in furtherance of the aims of the Royal Statistical Society and in accordance with the 1998 Data Protection Act.
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FOR OFFICE USE ONLY
Date received
Amount
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