By Post To:By Email To

LICENSED GAS TECHNICIAN APPLICATION FORM / If you require assistance or advice please call Membership Services on +44 (0)1509 678 152
or visit:
(Please write clearly in block capitals)
A)Contact Details
Title / Business Address
Surname
Forename
Other Names / (B) Tel. No. / Post Code
Date of Birth / Home Address
Gender
Mobile No.
Email address / (H) Tel. No. / Post Code
Present Grade of Membership & Membership No. / Which address do you wish IGEM to use for mailing?
(if applicable) / Business / Home
B)Gas Safe Details
Registration Number / Licence Number
No. of years registered with Gas Safe / ACS Reassessment Date
C)Technical Education, Academic Qualifications and Training/Professional Development (Please provide details of the IGEM approved qualification that you have achieved. Please use separate sheet if necessary)
Start & Finish Dates / Qualification (NVQ L2, Craft Certificate etc.) or Training/Professional Development Achieved / College/Training Centre / Date of Award
D)How did you hear about IGEM? (Please mark boxes with an ‘X’)
Employer / Gas Safe / IGEM Event
IGEM Website / Member Recommendation / Publication/Magazine
Trade Show / Word of mouth / Other
IGEM INTERNAL USE ONLY:
Received Date: / Fees received: / First Review Date: / Academic Qualifications:
Training and Experience (years): / References Supplied: / Membership Committee Decision: / Membership Number:
E)Engineering Experience including current position (within the last 5 years starting with most current)
Start & Finish Dates / Company Name / Job Title
Exact nature of duties
Exact nature of duties
Exact nature of duties
F)References (Please complete this section, unless your company has a Customer Service Scheme that has been assessed and approved by IGEM)
Please provide the names and contact details of two customers that you have carried out work for, within the last 12 months and who are willing to be contacted as a reference. You must contact them beforehand to ensure they are happy to be approached by IGEM, in support of your application.
Name / Name
Company / Company
Address / Address
Telephone / Telephone
Email / Email
G)Declaration by Applicant
I, the undersigned, hereby apply for election as/transfer to LICENSED GAS TECHNICIAN of the Institution of Gas Engineers & Managers and certify that the statements contained herein are true. If elected/transferred, I will observe the relevant By-laws, Regulations, Code of Conduct and Customer Charter.
Signature of Applicant / Date
Data Protection
IGEM takes your privacy very seriously and we are committed to safeguarding and respecting your personal information. Your personal data is stored on our membership database and treated with the highest confidentiality in accordance with the IGEM privacy policy
H)Payment Details (Please mark boxes with an ‘X’)
Grade of Membership / Application Fee / X / Transfer Fee / X
Licensed Gas Technician / £30.00 / £20.00
Plus payment of the relevant Membership Subscription Fee - £65.00
For details of Membership Subscription fees due please refer to the fee sheet.
I wish to pay by:
Cheque (Please make payable to ‘IGEM’ and write your Name and Date of Birth on the reverse)
Debit/Credit Card (Please complete the payment section below)
Card No. / / / / / /
Expiry Date / / / 3 digit Security Code
Name as it appears on the card
Applicant Checklist (Please make sure you mark all boxes with an ‘X’)
a)All Sections of the application form have been completed
b)Provided IGEM with copies of certificates for all qualifications listed in section C
c)References provided in Section F
d)Completed payment details in Section H
e)Signature provided in Section G
If you have marked all the above boxes, you are ready to send your application to IGEM:

By Post to:By Email to:

Membership

IGEM

IGEM House

28 High Street

Kegworth

DerbyshireTelephone:

DE74 2DA+44 (0)1509 678152

P/07/11–V2Form - LGT