Thanks for signing up for Student membership – please fill out this form in BLOCK CAPITALS

PERSONAL DETAILS
Surname: / Forename(s): / Title:
Home
address:
Postcode:
Email:
Home Telephone: / Mobile:

The address provided above will be where all postal and email communication will be sent. Should you move whilst you are studying,or no longer use the email address provided above, please let us know.

How did you learn about CIEEM?
EDUCATION (Current Course)
Is your course accredited by CIEEM? Yes No
Course title: / Qualification level (e.g. BSc):
Institution/ awarding body:
Date started
(mm/yy): / Completion date (mm/yy):
Full/part time: / Student or NUS Number
CIEEM may contact your course tutor to verify any aspect of your application and your status as a student enrolled on the course detailed above. Therefore, please provide the following information:
Name of Course Leader or Tutor:
Course leader/Tutor E-mail:

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I understand that my application for membership may be refused, or my membership may be later withdrawn, if I have provided false or untrue information or if I am found not to have complied with the Membership Regulations or Code of Professional Conduct.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

  • 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.
  • Your application will be acknowledged upon receipt and payment will be processed.
  • Any charges incurred by CIEEM due to underpaid postage will be your responsibility.
  • Receipts for subscriptions and any appropriate refunds are provided at the time of admission to CIEEM

Please tick one box and complete details as appropriate:

I wish to pay by debit/credit card, please charge to my account the amount of:£22.00 (£12 for students on CIEEM accredited degrees)
Card number: / Start date: / End date:
Name on Card: / Issue number: / Security no:
Address of cardholder:
Signature: / Date:
Please post this form to:
CIEEM, 43 Southgate Street, Winchester,
Hampshire SO23 9EH
Or email it to:
Please refer to CIEEM’s Membership Regulations and Code of Professional Conduct found on the CIEEM website.Please ensure that you have filled out this form fully and accurately. Processing usually takes 4-6 weeks. / OFFICE USE
Date received:
Payment:
Missing details:
Notified of outcome:

08/2017