APPLICATION FOR MEMBER/FELLOW OF CIBSE

Please tick as appropriate

MCIBSE FCIBSE
Please indicate whether New (not previously a member of CIBSE) or, Transfer (already CIBSE member) Membership. No Grade
CIBSE Use Only Batch No. .………………...………. Amount …………………..….……. Date …………………….…..…….. Membership No.. ……..…………… ENQ: ……………………………… Code: PD-WEB

Have you previously applied to join the CIBSE? (state Y/N in the box) Already CEng 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 1. PERSONAL DETAILS First Names Title Yes/No (delete as appropriate)

Surname Date of Birth (DD/MM/YY) (tick box for preferred contact address) Private Address 

Business Address  Company name

Post Code Tel email Mobile Fax Tel email

Post Code Fax

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

Please submit 3 hard copies in total PLUS a CD Rom version of this form and all supporting documentation.
What prompted you to submit this application? Select ONE 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 CIBSE HQ use only:

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MCIBSE or FCIBSE - Version 17/ Date of issue: June 2012

sandwich. 4 ENGINEERING PRACTICE REPORT New applicants: Please append a completed Engineering Practice Report of approximately 4000 words. See fact sheets M20 (for Member) or F20 (for Fellow) 7 MAIN ENGINEERING DISCIPLINE Please indicate from the list below your main area of expertise in building services engineering. the posts you have held. Academia M&E Electrica l Mechanica l Energy Management Public Health Othe r Environmenta l Facilities Management If you have ticked Other. Your Report should be based on the Competence Criteria for MCIBSE/FCIBSE (fact sheet M21/F21). full details of the companies you have worked for. 6 DEVELOPMENT ACTION PLAN All those wishing to join CIBSE are required to show commitment to maintaining their professional capabilities and knowledge.Version 17/ Date of issue: June 2012 . North West South West London and South East North East Scotland East Midlands West Midlands 2 of 5 MCIBSE or FCIBSE . Please append your Development Action Plan stating your short. P/T.) * *F/T = full time P/T = part time 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. EDUCATIONAL QUALIFICATIONS (Please list all your post school qualifications and indicate any exemptions granted and details of any interruptions to your course). medium and long term goals and your intended actions to attain those goals. your preferred location and we will take this into account when arranging your interview. Advice on how to put together your Report is in fact sheet M20/F20. please specify: 8 INTERVIEW Please circle. 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 gained including subject area Date course commenced Course duration Date qualification obtained Mode of Study (F/T. etc. or indicate clearly. This information will assist CIBSE in allocating an appropriate assessor to appraise your application. Applicants transferring from Member to Fellow : Separate form available Please indicate if you have followed a CIBSE approved training programme YES NO 5 ORGANISATIONAL CHART Please append a chart indicating your position in the organisation.2. It should include a brief introduction and be countersigned by your Sponsor. and level of responsibility.

that I agree to abide by the Code of Professional Conduct. CIBSE reserve the right to withdraw membership of the Institution and discipline the applicant under the Code of Professional Conduct. I confirm my support for this application at the grade applied for.. ……………………………………………………………………. If you do not wish your application to be used for this purpose. 10 APPLICANT’S DECLARATION I certify that the information contained in this application and supporting documents is correct. ………………………………………… ………………………………………… ………………………………………… ………………………………………… Institution membership: Name of Institution: ………………………………………………………….. I shall. and do all in my power to advance the objects of the Institution. CIBSE seeks to provide the best possible support to candidates. after payment of any arrears which may be due by me at that period. …………………………………………………………………….. 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. in the event of my election to any class of membership of the Chartered Institution of Building Services Engineers. providing that whenever I shall signify in writing to the Secretary that I wish to withdraw from the Institution. be free from this obligation. Signed Address ……………………………………. who is FCIBSE. ……………………………………………………………………. From time to time. MCIBSE or registered CEng with any Engineering Council Nominated Institution or professionally registered within the construction industry... Sponsors may be contacted by CIBSE for confirmation of their support of the applicant. Telephone Mobile Email Post Code Date ………………. Signed ……………………………………………………………………………. Should sponsors wish to provide additional information to the Institution they can do so by corresponding directly with the Membership Officer at CIBSE. please tick here  Thank you for helping us help others! NB: Your name and contact/payment details will not be divulged.. years If you are professionally registered with a non-Engineering Council nominated institution. In the event of it coming to light that information supplied on this form is inaccurate. NB. please send a copy of your registration certificate with this application..Yorkshire 9 SPONSOR Wales Northern Ireland Ireland Hong Kong Australia United Arab Emirates Qatar All applicants must provide one sponsor. ……………………………………………………………………. EC registration grade …………………… Known applicant ………. I agree that. I confirm that I have seen the original qualification certificates referred to in the application and have initialled photocopies of them. The sponsor should have known you for a minimum of one year. To the best of my knowledge. we use applicants’ material to illustrate best practice. all the information contained in this application and supporting documents is correct. Print Name ……………………………………………………. SPONSOR’S DECLARATION I confirm that I have known the applicant for a minimum of one year.Version 17/ Date of issue: June 2012 . 3 of 5 MCIBSE or FCIBSE . Date ………………………………………… NB.

including full postal code _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ * Delete where appropriate. See Fact Sheet I20 for details of Application Fee and other fees. YES NO Decision 4 of 5 MCIBSE or FCIBSE . --------------------------------------------------------------------------------------------------------------------------------------------------FOR OFFICIAL USE ONLY Application Fee PR/CR Fee Paid Paid EC Qualification Code (if any) CIBSE Panel Meeting Date Registration Panel Meeting Date Decision: Decision: ICP No.11 FEES Please send appropriate fees with this application (excluding annual subscription). Cheques should be made payable to CIBSE or by credit card below * Payment attached / please debit my: MasterCard With £_____________ Vis a Visa Delta Switch Cardholder’s Name: ________________________________________________ Card Number: Card Expiry Date: Security Code: / Date: Issue No (if Card Start / applicable: (Last 3 digits on the reverse of the card) Cardholder’s signature: _________________________________________________ Cardholder’s address.Version 17/ Date of issue: June 2012 .

278104 222 Balham High Road. London.Version 17/ Date of issue: June 2012 . SW12 9BS Telephone 020 8675 5211 Fax 020 8675 5449 5 of 5 MCIBSE or FCIBSE .Please return to: Membership Department CHARTERED INSTITUTION OF BUILDING SERVICES ENGINEERS Incorporated by Royal Charter 1976 Registered Charity No.

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