Conservation Register Membership renewals 2011-12

Personal Details

Name:* / PracticeNumber:
Name of Practice:*
Address:*
Telephone (day):* Mobile:*
Email:*
* mandatory fields

Declaration

Continued inclusion on the Conservation Register is not automatic and depends on satisfactory completion of this form and ongoing compliance with the Conservation Register criteria for inclusion. The criteria describe basic standards and inclusion in the Conservation Register does not constitute a recommendation or an approval of the quality of work undertaken. The Conservation Register Advisory Board reserves the right to remove, omit, restore or vary any entry at any time without giving reasons. Not all the information that you provide us with will be made available to clients. All the information that you submit is held under secure conditions by the Institute of Conservation. (see our Privacy Policy)

Please read and sign the declaration below:

  • I declare that my conservation practice meets the criteria for inclusion on the Conservation Register. ( agree to the details of my conservation practice being included in the Conservation Register as stated. (There may be a reason ie security why a member wouldn’t want their full contact details being made publicly available but that we would want them for administrative purposes)
  • I understand that the Conservation Register Advisory Board does not undertake to automatically include my practice in the Conservation Register and that it reserves the right to make its own decision as to whether to do so.
  • The information I have provided in this form is accurate to the best of my knowledge and belief.
  • I agree to update my samples of work every two years as part of the review process. I understand that Icon reserves the right to monitor changes to members’ data. I understand that Icon reserves the right to contact referees for validation of my samples of work.

Signature:
Name (printed):
Date:

Please turn over for payment details.

Payment Details (please tick as appropriate)

Amount due: £ …………….. (please complete)
 / I enclose a cheque for £……………....
Made payable to the Institute of Conservation(please write your invoice number on the reverse of the cheque)
OR
 / I wish to pay £…………… by credit/debit card (excluding AmEx or Diners)
Name on Card
Card Number
Start Date or Issue Number
Expiry Date
Security Code *
Signature
(* 3 digit number on the reverse of your card, we are unable to process your payment without this)
OR
 / I wish to pay by BACS(please quote your invoice number as a reference)
Account Name: Institute of Conservation
Account Number: 00012735
Sort-code: 40-52-40
OR
 / I wish to pay by quarterly direct debit (UK bank accounts only)
please contact the office for a mandate form –

For your receipt please visit and login into your practice page, you will be able to download this form the documents button at the bottom of your practice summery.

Please return this form by post together with your payment to:

Conservation Register, c/o Icon

1.5 Lafone House, The Leathermarket, Weston Street, London, SE1 3ER