application form for StudentGraduate membership

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					                            APPLICATION FOR GRADUATE OF CIBSE



                                                                                                                      CIBSE Use Only
Please indicate whether
                                                                                                           Batch no. ………………………………
        New                                                                                                Amount …………………………………
        (not previously a member of CIBSE) or,
                                                                                                           Date …………………………………….
        Transfer (already        Membership.
        CIBSE member)                    No                            Grade                               Membership No. ……………………….

                                                                                                           ENQ: . …………………………………

        Have you previously applied to join CIBSE? (state Y/N in the box)                                  Code: PD-WEB

        Already CEng Stage 1 Registered? (state Y/N in the box). If yes, please give Registration number
        and the Institution through which you are Registered. Please attach proof of Registration.


                                                                                                    Proof attached   Yes/No (delete as appropriate)


1.    PERSONAL DETAILS

Surname                                                      First Names                                               Title

Date of Birth (DD/MM/YY)

(tick box for preferred contact address)
Private Address                                                        Business Address

                                                                       Company name




                                   Post Code                                                                    Post Code

Tel                                Fax                                 Tel                                    Fax

email                                                                  email

Mobile


Please tick here if you do not wish to receive external mail


What prompted you to submit this application? Select ONE only:                   CIBSE HQ use only:
   Contacted by CIBSE 
   Advised by colleague/boss 
   Attended a membership briefing session 
   Looked at the CIBSE website 
   Approached at a CIBSE event 
   Saw article/advert in industry publication 




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2. EDUCATIONAL QUALIFICATIONS
Please list all your post school qualifications and indicate any exemptions granted and details of any interruptions to your course. Awards shown
must be accompanied by a photocopy of the original certificate countersigned by your Sponsor as having seen the original

University or College                      Full title of qualifications          Date course      Course           Date                   Mode of Study
                                           gained including subject area         commenced        duration         qualification          (F/T, P/T,
                                                                                                                   obtained               sandwich, etc.) *




Current studies and envisaged completion date:
University or College                 Full title of qualifications               Date course      Course           Envisaged              Mode of Study
                                      including subject area                     commenced        duration         completion             (F/T, P/T,
                                                                                                                                          sandwich, etc.) *




*Mode of Study :
Full-time (F/T) includes courses which incorporate a year out work experience placement. Part-time (P/T) includes distance learning.

         Full time                     Part time                     Sandwich


3. EMPLOYMENT DETAILS
Please append a typewritten curriculum vitae providing full details of your work experience within the field of building services engineering: with
dates, full details of the companies you have worked for, the posts you have held, and level of responsibility.


4. SPONSOR
Please provide one sponsor, who is a Corporate member of CIBSE, or Registered CEng with any Engineering Council Nominated Institution

NB. Sponsors may be contacted by CIBSE for confirmation of their support of the applicant. Should sponsors wish to provide additional information
to the Institution they can do so by corresponding directly with the Membership Officer at CIBSE.

5. SPONSOR’S DECLARATION
I confirm that to the best of my knowledge, all the information contained in this application and supporting documents is correct. I confirm that I
recommend the applicant, from personal knowledge, as a proper person to become a Graduate of CIBSE, subject to By-Laws


Signed     …………………………………..                         Print Name      ……………………………………………………                                            Date     ……………….

Institution membership:
Name of Institution:  ……………………………………………………

EC registration grade      …………………….                Known applicant       ……….         years

6. APPLICANT’S DECLARATION
I certify that the information in this application and supporting documents is correct. I agree that, in the event of my election to any class of
membership of the Chartered Institution of Building Services Engineers, I will be governed by the provisions of the Royal Charter and By-laws as
they are now formed or as they may be hereafter altered; that I agree to abide by the Code of Professional Conduct, and do all in my power to
advance the objects of the Institution; providing that whenever I shall signify in writing to the Secretary that I wish to withdraw from the Institution, I
shall, after payment of any arrears which may be due by me at that period, be free from this obligation.

Signed      ………………………………………………………………………………….                                                         Date     ………………………………………..

NB. In the event of it coming to light that information supplied on this form is inaccurate, CIBSE reserve the right to withdraw membership of
the Institution and discipline the applicant under the Code of Professional Conduct.


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 7.    FEES

 Please send a non-refundable application fee of £15.00 with this application. (Please see fact sheet I20 for details of annual subscription fees,
 payable on election).
 Cheques should be made payable to CIBSE or by credit card below

* Payment attached / please debit my: MasterCard                      Visa       Visa Delta          Switch

 With £_____________

 Cardholder’s Name:           ________________________________________________

 Card Number:


 Card Expiry Date:                  /                         Card Start Date:                 /


 Security Code:                        Issue No (if applicable:
(Last 3 digits on the reverse of the card)

 Cardholder’s signature: _________________________________________________
 Cardholder’s address, including full postal code
 _____________________________________________________________________
 _____________________________________________________________________
 _____________________________________________________________________
 _____________________________________________________________________
 * Delete where appropriate.



 FOR OFFICIAL USE ONLY

      Application                               Paid
             Fee


                     EC Qualification Code (if any)


 CIBSE Panel Meeting Date                                                      Decision:
 Registration Panel Meeting Date                                               Decision:


      ICP No.        YES       NO                                                       Decision




 Please return to: Membership Department
 CHARTERED INSTITUTION OF BUILDING SERVICES ENGINEERS
 Incorporated by Royal Charter 1976                   Registered Charity No. 278104
 222 Balham High Road, London, SW12 9BS               Telephone 020 8675 5211
                                                      Fax 020 8675 5449




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