Membership application form

PLEASE USE BLACK INK AND WRITE IN BLOCK CAPITALS. If you require assistance or advice, please telephone the Member and Customer Services Centre on +44 (0) 1438 765678 or email membership@theiet.orgYour subscription year will run annually from the month that you join the Institution. If you would like to apply for student membership then log on to the student website www.theiet.org/circuitPLEASE SEND THE COMPLETED FORM TO: THE INSTITUTION OF ENGINEERING AND TECHNOLOGY, PO BOX 96, STEVENAGE, SG1 2SD, UKA: YOUR DETAILSPlease specify the address that you would like all correspondence to be sent to.Home Work Please specify gender. Male Female(Only required for existing members or previous members wishing to join the Institution of Engineering and Technology)Where did you first hear about the Institution of Engineering and Technology?Friend Event Post Advert Member InvitationPresentation Email TelephoneOther, please specifyIs your membership fee being funded by your employer?Yes No If yes, please ensure you have completed the work details sectionMembership NumberWork EmailWork Tel NoPostcodeWork AddressCompany or University Name (if applicable)Job TitleEmailTel No/MobilePostcodeHome AddressDate of BirthLast NameFirst Name(s)TitleB: YOUR MAGAZINESAs part of your membership package, in addition to your monthly copy of Engineering and Technology Magazine, you will also receive bi-monthly one of the magazines listed below.Please choose ONE magazine you wish to receive.ElectronicsControl & AutomationManufacturingEngineering ManagementInformation ProfessionalCommunications EngineerPowerYou can change your choice of magazine at any time by visiting www.theiet.org/myC: DECLARATIONI declare that the statements made on this form are to the bestof my knowledge true. I confirm that I have not committed anyoffence of which the Institution of Engineering and Technology(IET) would require me to give notice under its Rules ofConduct. I agree to comply with the Royal Charter and Byelawsof the Institution and whilst remaining a member I will do mybest to promote the interests of the Institution.I understand and consent to the information provided on thisform being processed by the Institution for its sole use and thatof its associated organisations for the purposes of promoting,delivering and improving my experience of the Institution, itsproducts and its services, by post and electronic means. TheRules of Conduct and the Royal Charter and Byelaws are published on the website www.theiet.org/byelawsW(03)The Institution of Engineering and Technology is a not for profit organisation, registered Charity No. 211014DateSignature of ApplicantPage 1 of 3M App A4 Form BW Jan 2007 Update v3.qxd 4/1/07 11:31 am Page 1Membership Application FormThe Institution of Engineering and TechnologyLine Manager Institution Member TMIET MIET FIET CEng IEng EngTechPlease detail membership of other Institutions e.g. MIMechE, MIEAust: Membership Number (if applicable)Other, please specifyJob TitleLast NameFirst Name(s)TitleIn my opinion this person has achieved the required knowledge and understanding and is a suitable candidate to become a member of theInstitution and use the letters MIET or TMIET after their name.DateSignature of SupporterEmailTel No/MobilePostcodeAddress for CommunicationD: DESIGNATORY LETTERSTo find out the requirements for each category of membership visit www.theiet.org/membership/categories. OT/MORF YDUTS FO DOIREP TNEMHSILBATSE LANOITACUDEELTIT ESRUOC)EERGED SNOH FI ETATS( ESRUOC/DRAWAOR AWARDING BODY AND COUNTRYCURRENT PREVIOUSWhen providing a CV clearly detail your present employment position, previous employment positions and any roles, responsibilities and other qualifications that are relevant to the interests of the Institution.SUPPORTER’S DETAILSIf you cannot find a suitable person to support your application, please contact the Member and Customer Services Centre on +44 (0) 1438 765678.Your supporter can be your employer, a member of the Institution or someone that knows you in a work capacity. I do not wish to apply for designatory lettersI do not wish to apply for designatory letters at the moment.Please contact me about this at a later date.I wish to apply for the designatory letters MIET (Please complete the Qualifications and Supporter Details Sections)I wish to apply for the designatory letters TMIET (Please complete the Qualifications and Supporter Details Sections)QUALIFICATIONSPlease provide details of science, engineering and technology qualifications that you have completed or are in the process of completingMEng MSc PhD NVQ 5 BEng BSc NVQ 4 ONC OND HNC HND CSCS/ECS Platinum Card Advanced Modern Apprenticeship Level 3 NQF Level 6 (SQCF) Foundation Degree City and Guilds 236 (Electrical installation or similar) City and Guilds Higher Professional Diploma in Engineering CSCS/ECS Gold card Non UK qualifications, please supply a CV Other, please supply a CV None, please supply a CVPlease specify your qualification details in the table below.Page 2 of 3M App A4 Form BW Jan 2007 Update v3.qxd 4/1/07 11:31 am Page 2E: YOUR PAYMENT OPTIONSSubscription Rates from 1 January 2007Members and members with 00.79£TEIMT ro TEIM designatory letters eht00.21£secitnerppa dna stnedutSIf you are professionally registered, you are required to pay the qualificationmaintenance fee. This will be in addition to your membership subscription fee:Institution registered Fellows, Chartered and Incorporated Engineers and Chartered Electrical Engineers will pay an addition of £20.00.Institution registered Engineering Technicians will pay an addition of £5.00If your annual income from all sources is less than £18,000, or its equiva-lent in local currency, then you may claim a 50% reduction** from the fullsubscription fee. However, this concession is not available to you if you are claiming a student rate.I would like to apply for a reduced subscription** Please note that the Institution reserves the right to contact your employer to verify this claim.If you are applying for membership from India and mainland China thenplease visit www.theiet.org/membershipfees to find out about the rates setin the local currency of Renminbi (RMB) for members in mainland Chinaand Rupees for members in India.F: PAYMENT AMOUNT1: Subscription fee £2: I would like to donate £5 or £ to IET Connect, the Institution’s Benevolent Fund1. I am a UK taxpayer and would like IET Connect to reclaim the tax on this and all future payments under the Gift Aid Scheme.3: Total £1IET Connect, the Institution’s Benevolent Fund asks each member to donate at least £5 with their membership subscription each year. For more information on the services available visit www.ietconnect.org. IET Connect is a separate registered charity affiliated to the Institution.TFARD KNAB GNILRETS/EUQEHCTIBED TCERIDDRAC:yb yap ot hsiw IPlease complete the Payment Please complete the Direct Debit Please make this payable to The Institution ygolonhceT dna gnireenignE fowoleb noitcurtsnIwoleb noitces draC yBG: PAYMENT DETAILSPAYMENT BY CARDI authorise you to charge my Visa/Mastercard/American Express/Maestro/Delta*with: *Please delete as appropriatea one-off payment with the amount stated in Section F for my current year’s subscription.the amount stated in Section F for my current year’s subscription and payment of unspecified amounts for future years’ subscriptions as and when they become due (Visa/Mastercard only). I understand that I will be given prior notice in writing.Card NumberIssue Number 3 or 4 digit card security code (CSC)Membership Number (Please complete if applicable)DateSignatureCountryPostcodeAddressName on credit card Valid from [m] [m] [y] [y]Expiry date [m] [m] [y] [y]INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY BY DIRECT DEBITPlease fill in the whole form using a ball point pen and send to: The Institution ofEngineering and Technology, PO Box 96, Stevenage, SG1 2SD, United KingdomName and full postal address of your Bank or Building SocietyName(s) of Account Holder(s)Bank/Building Society Account Number Branch Sort CodeOriginator’s Identification Number9 2 0 0 1 5Instruction 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 thisinstruction may remain with the Institution and, if so, details will be passed electronicallyto my Bank/Building Society.DateSignature(s)Reference (For office use only)PostcodeAddressyteicoS gnidliuB/knaBreganaM ehT :oTThis guarantee should be detached and retained by the Payer.The Direct Debit Guarantee• This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme.The efficiency and 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 of Engineering and Technology will notify you 14 working daysin 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 of the amount paid.• You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy of your letter to us.Page 3 of 3M App A4 Form BW Jan 2007 Update v3.qxd 4/1/07 11:31 am Page 3