GAS TECHNICIAN APPLICATION FORM If you require assistance or advice please call Membership Services on +44 (0)1509 678 152 or visit: www.igem.org.uk/membership/grades.asp

(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) Gas Safe Details

Registration Number       Licence Number      

ACS Reassessment Date      

C) Present Employment (Further information may be given on separate sheets if necessary)

Dates Company Name Job Title

                 

Brief description of duties      

D) Declaration by Applicant

I, the undersigned, hereby apply for election as/transfer to GAS TECHNICIAN of 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      

IGEM INTERNAL USE ONLY:Received Date: First Review: IGEM Decision: Membership No.:

Fees:

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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 www.igem.org.uk/privacy

E) How did you hear about IGEM? (Please mark boxes with an ‘X’)

Employer Gas Safe IGEM Event

IGEM Website Member Recommendation Publication/Magazine

Trade Show Word of mouth Other      

F) Payment Details (Please mark boxes with an ‘X’)

Grade of Membership Application Fee X Transfer Fee X

Gas Technician £30.00 £20.00

Payment of the relevant Membership Subscription Fee £53.00

For details of Membership Subscription fees due please refer to the fee sheet.

I wish to pay by:

Cheque (Please make payable to ‘IGEM’ and write your Name and Date of Birth on the reverse)

Debit/Credit Card (Please complete the payment section below)

Card No.         /         /         /        

G) Applicant Checklist (Please make sure you mark all boxes with an ‘X’)

a) All Sections of the application form have been completed

b) Provided IGEM with Gas Safe registration details in Section B

c) Completed payment details in Section F

d) Signature provided in Section D

If you have marked all the above boxes, you are ready to send your application to IGEM:

By Post to: By Email to:Membership Services membership@igem.org.ukIGEMIGEM House28 High StreetKegworthDerbyshire Telephone:DE74 2DA +44 (0)1509 678152

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Expiry Date     /     3 digit Security Code      

Cardholders Name