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.

______

FOR OFFICE USE ONLY

Date received

Amount

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