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					Academic Assessment Application Form
ICE 3120
Graduate Membership* and eventual progression to Member (CEng) Graduate Membership* and eventual progression to Member (IEng) Graduate Membership* and eventual progression to Technician Member (EngTech)
*You should also note that following the meeting of the AQP you will be admitted as a Graduate Member and therefore an annual subscription will be payable in due course (details available on the ICE website). Please consult MGN 4 which is available on the ICE Website (www.ice.org.uk/membershipdownloads)before completing this form.

Personal information:
ICE Membership No:
(If applicable)

Current Grade:
(If applicable)

Year of admission:
(If applicable)

Surname: First name(s): Nationality:

Title: Date of Birth: Gender:

Home Address:
Address Line 1: Address Line 2: Address Line 3: Country: Postcode: Telephone: Fax: Contact e-mail:

Employment:
Employers name: Address Line 1: Address Line 2: Address Line 3: Country: Postcode: Telephone: Fax: Contact e-mail: Position held: Start Date:

Academic Qualifications (Undergraduate and Post Graduate)
Give details of academic qualifications. Single, certified true, photocopies of certificates and other supporting documents must accompany this form. In the case of a higher degree, indicate whether this was obtained by examination or by dissertation/thesis. If the latter, please give details. Awarding College/University
(in order attained)

Qualification
(HND, BEng, BSc etc)

Course Title

Attendance Type
(Full, Part time, sandwich etc)

Class
(1st, 2;i, etc)

Start Date
(mm/yy)

End Date
(mm/yy)

Education & Learning ICE3120

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Version 1 Revision 3 – 25 June 2009 Registered Charity 210252

Certification of Qualifications
A photocopy of any qualifications held must be submitted with this application and certified as a true copy*. If evidence of the qualifications are not submitted/authenticated, a delay to the processing of your application may occur. *The certified copy must be a "true copy of the original" of your academic qualification AND your University lecturer, senior member of your employing company, or a Corporate ICE Member, must write the following in blue or black pen directly onto the proof of academic qualification: "I confirm this to be a true copy of this applicant's qualification and recommend him/her as a Graduate to ICE" Signature: Name (clearly printed): Date: Employing organisation/university or college: A contact telephone number or email address: Please note: We may need to contact your University/College or Professional Institution to verify the authenticity of your qualification. If any qualifications are identified as fraudulent the application will be rejected.

Please ensure you have included the following:
(failure to provide all required information may cause a delay in the processing of your application)

Completed and signed application form (please ensure all sections of the application form fully completed) Certified copies of your academic qualifications (please refer to the certification guidelines above) List of Subjects studied (official transcript or Diploma Supplement preferred) (for each qualification) Title and 1 page synopsis of your final year project (for your completed bachelors degree) Title and 1 page synopsis of your dissertation (if you have completed a higher level degree course) Detailed CV Application Fee details available on the ICE Website (www.ice.org.uk/fees)
PLEASE NOTE: ALL DOCUMENTATION PROVIDED MUST BE COPIES OF THE ORIGINAL, AS THESE DOCUMENTS WILL NOT BE RETURNED AFTER THE ASSESSMENT. ALSO DOCUMENTS NOT IN ENGLISH, SHOULD BE ACCOMPANIED BY AN ENGLISH TRANSLATION CERTIFIED AS CORRECT BY AN OFFICIAL TRANSLATOR, SENIOR MEMBER OF YOUR EMPLOYING COMPANY OR A CORPORATE ICE MEMBER.

Payment
Please complete the form on page 3 to pay by Credit/Debit Card . Alternatively if you wish to pay by Cheque, please make paya ble to ‘Institution of Civil Engineers’ and include with this application.

Important undertaking to be signed by the candidate I apply for an Academic Assessment and admission as a Graduate Member of the Institution of Civil Engineers. I promise that in
the event of my admission I will be governed by the Royal Charter, By-laws, Regulations and Rules of the Institution and I will accept as final and binding the decisions of the Council. I also promise to promote the object of the Institution to foster and promot e the art and science of Civil Engineering and to attend its meetings as often as I conveniently can. I declare the information in this application to be complete and correct. Signed: Date:

Data Protection Act (DPA) 1998: The ICE maintains data on members, including addresses, professional history and interests where notified. This will be used confidentially for normal purposes, including subscription collection, mailing of publications, and notification of conferences and meetings. Occasional mailings are undertaken on behalf of carefully screened third parties. If you DO NOT wish to receive any promotional material, please tick this box:

Please return to: ICP Executive, Education & Learning, Institution of Civil Engineers, One Great George Street, London, Westminster, SW1P 3AA, UK T: 020 7665 2147 F: 020 7233 0515 E: aqp@ice.org.uk W: www.ice.org.uk
Education & Learning ICE3120 Page 2 of 3 Version 1 Revision 3 – 25 June 2009 Registered Charity 210252

Payment By CREDIT or DEBIT Card Surname: First name(s): Telephone: Email: Membership No: (if applicable)

CREDIT/DEBIT CARD No:
(we do not accept AMEX, Diners Club, Electron or Solo)

Cardholders Name: Expiry Date:

SWITCH/MAESTRO CARD No:
(UK account holders only)

Cardholders Name: Start Date: Expiry Date:

Issue No:

Nature of Payment:
e.g. Chartered Professional Review Fee

Academic Assessment Application Fee ACAPROF09 £35

Product Code (Staff use only):

I Authorise You To Collect The Amount Of:

Cardholders Signature:

Date:
Please return to: ICP Executive, Education & Learning, Institution of Civil Engineers, One Great George Street, London, Westminster, SW1P 3AA, UK T: 020 7665 2147 F: 020 7233 0515 E: aqp@ice.org.uk W: www.ice.org.uk

Education & Learning ICE3120

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Version 1 Revision 3 – 25 June 2009 Registered Charity 210252


				
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