Apprentice membership application form

Please use black ink and write in BLOCK CAPITALS.If you require assistance or advice please telephone +44 (0)1438 765678 or email membership@theiet.org. Your annual subscription must accompany this form. Your subscription year will run annually from the date that you joined the Institution of Engineering and Technology. If you wish to apply and pay online visit www.theiet.org/join you will require a Credit or Debit card. Send the completed application form to: The Institution of Engineering and Technology, Apprentice Applicant, PO Box 96, Stevenage, SG1 2SD, United Kingdom YOUR DETAILS DOBTitle First Name(s)Last NamePermanent AddressPostcode CountryEmployment Name and AddressPostcode CountryApprentice MemberW(03)APPPreferred E-mail AddressTelephone MobileTelephoneQUALIFICATIONS AND TRAININGName of CollegeCourse Start Date 1st 2nd 3rdSignature DateOBLIGATION AND CERTIFICATE*The Rules of Conduct and the Royal Charter and Byelaws are published on the website www.theiet.org/byelawsPlease send me, by electronic means or post, information relevant to me about third party events, products and servicesI declare that the statements made on this form are to the best of my knowledge true. I con?rm that I have not committed any o?ence of which the Institution of Engineering and Technology would require me to give notice under its Rules of Conduct. I agree to comply with the Charter and Byelaws* of the Institution and whilst remaining a member I will do my best to promote its interests. I understand and consent to the information provided on this form being processed by the Institution for its sole use and that of its associated organisations for the purposes of promoting, delivering and improving my experience of the Institution, its products and its services by post and electronic means.YOUR FREE MAGAZINESAs part of your membership package you will receive a monthly Engineering and Technology Magazine and a Student and Graduate Magazine three times a year. On top of this, you will also receive ONE bi-monthly industry speci?c magazine relevant to your interests/studies. Please choose the ONE industry magazine that you wish to receive.Engineering ManagementInformation Professional Manufacturing Power EngineerElectronicsControl and AutomationCommunications EngineerWhat year of your Apprenticeship are you currently in: 4thAnticipated End Date Scheme Provider Approval Number (if applicable) Scheme Provider Name and Address Award e.g. HND, NC Course TitlePLEASE COMPLETE PAYMENT DETAILS ON THE FACING PAGE AND SEND TO The Institution of Engineering and Technology, Apprentice Applicant,PO Box 96, Stevenage, SG1 2SD, United KingdomWhere did you ?rst hear about the Institution?SUBSCRIPTION RATES (please tick appropriate box)£12 for 1 Year £24 for 3 Years £30 for 4/5 Years YOUR PAYMENT OPTIONSIf you are a UK Bank Account Holder, you can complete the Direct Debit Instruction on the next page. Direct Debit is a convenient method of payment and also reduces our administration costs to process subscriptions – this helps keep our fees down.Alternatively, you can make a single payment by completing the one-o? card charge authority or via cheque, sterling bank draft or by calling the credit card telephone number +44 (0)1438 765678. Cheques and Sterling Bank Drafts should be made payable to The Institution of Engineering and Technology and returned to: The Institution of Engineering and Technology, Apprentice Applicant,PO Box 96, Stevenage, SG1 2SD, United Kingdom.Apprentice Member PaymentThe Institution of Engineering and Technology is a not for pro?t organisation, registered Charity No. 211014OPTION 1: ONE-OFF CARD CHARGE PAYMENTCard No.Expiry DateValid FromI authorise you to charge my Visa / Mastercard / American Express / Maestro / Delta* with a one-o? payment of £m m y y m m y yIssue No. (if applicable)SignatureDateName on Credit CardAddressPostcode*Please delete as appropriateReference (For office use only)3 or 4 Digit Secutity CodeThis guarantee should be detached and retained by the Payer.THE DIRECT DEBIT GUARANTEEThis Guarantee is o?ered by all Banks and Building Societies that take part in the Direct Debit Scheme. The e?ciency and the security of the Scheme is monitored and protected by your own Bank or Building Society. If the amounts to be paid or the payment dates change, the Institution will notify you 14 working days in advance of your account being debited or as otherwise agreed. If an error is made by the Institution or your Bank or Building Society, you are guaranteed a full and immediate refund from your branch for the amount paid. You can cancel a Direct Debit at any time in writing to your Bank or Building Society. Please also send a copy of your letter to us. Name and full postal address of your Bank or Building SocietyyteicoS gnidliuB/knaBreganaM ehT :oTAddressPostcodeName(s) of Account Holder(s)Bank/Building Society Account NumberBranch Sort CodeSignature(s)OPTION 2: INSTRUCTION TO YOUR BANK OR BUILDING Please complete the form and send to: The Institution of Engineering and Technology, Apprentice Applicant, PO Box 96, Stevenage, SG1 2SD, United KingdomOriginator’s Identification Number9 2 0 0 1 5 SOCIETY TO PAY BY DIRECT DEBITReference (For office use only)DateInstruction to your Bank or Building SocietyPlease pay the Institution Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with the Institution and, if so, details will be passed electronically to my Bank/Building Society.?