If You Fully Completed the Application Form, You Are Ready to Send Your Application Toigem

FELLOW APPLICATION FORM / If you require assistance or advice please call Membership Services on +44 (0)1509 678152 or visit:
(Please write clearly)
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)Level of involvement with IGEM(Please provide evidence of how you have made significant contribution to IGEM, industry and/or engineering during your career)
C)Present Employment (Current Position)
Date appointed / Job Title
Company Name
Company Address
Post Code
To whom do you report? / Position
Who reports to you? / How many?
IGEM INTERNAL USE ONLY:
Received Date: / Application Fee: / First Review Date: / Sponsor Check:
Training and Experience (years): / Scrutineers: / Interview Details (if applicable): / Membership Committee Decision:
Further information on your current post (please give details of your duties & professional responsibilities in the gas industry or associated activities)
D)Engineering Experience (prior positions held within the last 5 years)
Further information may be given on separate sheets if necessary
Start & Finish Dates / Company Name / Job Title
Exact nature of duties
Exact nature of duties
E)Statement by the Proposer (The Proposer must be a Fellow or be registered with the Engineering Council)
I, the undersigned certify that the statements contained herein are to the best of my knowledge true. I am of the opinion that the applicant is a worthy candidate for consideration by the Council for the grade of FELLOW.
Full Name (in BLOCK capitals) / Title
Address / Post Code
Engineering Council Registration Number / Registration Grade
IGEM Membership Number
Signature / Date
F)Declaration by Applicant
I, the undersigned, hereby apply for transfer to FELLOW MEMBERof 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 and Code of Conduct.
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
G)Membership of other Engineering or Scientific bodies
Name of Institution
Membership Grade
Name of Institution
Membership Grade
Name of Institution
Membership Grade
H)Payment Details (Please mark boxes with an ‘X’)
Grade of Membership / Transfer Fee / X
Fellow / £50.00
PLEASE NOTE: Upon successful election Membership Services will write to you requesting the remaining Membership Subscription Fees.
I wish to pay by:
Debit/Credit Card (Please complete the payment section below)
Cheque (Please make payable to ‘IGEM’ and write your Name and Date of Birth on the reverse)
Card No. / / / / / /
Expiry Date / / / 3 digit Security Code
Cardholders Name

If you fully completed the application form, you are ready to send your application toIGEM:

By Post to:By Email to:

Membership

IGEM

IGEM HouseBy Fax to:

28 High Street+44 (0)1509 678192

Kegworth

DerbyshireTelephone:

DE74 2DA+44 (0)1509 678152

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