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Associate and Member Application Form 2012

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Please use black ink and write in BLOCK CAPITALS. If you require assistance or advice please telephone +44 (0)1438 765678 or visit www.theiet.org/contactmembership. 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. Please send the completed application form to: Membership Application Team, The IET, Michael Faraday House, Six Hills Way, Stevenage, Herts SG1 2AY UK.

A Your Details
Title Surname/Family Name Home Address County/State Home Telephone Home Email Address Postcode Personal Mobile Country First Name(s) Date of Birth

dd / mm / yyyy

B Employer Details
Job Title Work Address County/State Work Telephone Work Email Address Please specify the address that you would like all correspondence sent to: Home Work Please specify your gender: Male Female Postcode Work Mobile Country Employer’s Name (if applicable)

Membership Number (only required for previous Associates or Members wishing to re-join the IET): Is your membership fee being funded by your employer? Yes No If yes, please ensure you have completed the work details section above.

C Data Protection
I understand and consent to the information provided on this form being processed by the IET for its sole use and that of its associated organisations, including my Local Network, for the purpose of promoting, delivering and improving my experience of the IET and its product and services. If either now or in the future I am based outside the European Economic Area (the “EEA”), my information may be transferred outside the EEA (for example to my Local Network or IET Global Office) to enable me to benefit from the IET opportunities overseas. The benefits of IET membership are enjoyed by our members globally. However if you do not wish to receive notification of IET products and services which may be of interest and benefit to you (by post or electronic means) please tick this box. If you have a preference for receiving details of membership benefits please tick: Email Post

D Declaration
I declare that the statements made on this form are to the best of my knowledge true. I agree to comply with the Royal Charter and Bye-laws and Rules of Conduct of the Institution of Engineering and Technology (IET) and understand that this is a commitment to behave ethically within my profession. I will do my best to promote the interests of the IET. I confirm that I have not committed any offence of which the IET would require me to give notice under its Rules of Conduct. The Rules of Conduct and the Royal Charter and Bye-laws are published on the website www.theiet.org/byelaws

Signature

Date

dd / mm / yyyy

E Membership Category Options
To find out about the requirements for each category of membership visit www.theiet.org/membership/types

F Member Application Section
(Please refer to the guidance notes on the IET website www.theiet.org/requirements for further guidance in completing this section) I wish to apply for Member with the designatory letters MIET (please complete the Qualifications and Supporter Details sections) I wish to apply for Associate I wish to apply for Member with the designatory letters TMIET (please complete the Qualifications and Supporter Details sections) I wish to apply for Associate at the moment. Please contact me about designatory letters at a later date.

The Institution of Engineering and Technology is registered as a Charity in England & Wales (no 211014) and Scotland (no SC038698)

www.theiet.org

the IET Benevolent Fund1. The IET Benevolent Fund is a separately registered charity (Reg. Computing etc Name of University/College/Awarding Body and Country Period of Study (start and end date) Work Experience Please provide a CV that clearly details your present employment position. For more information on the services offered please visit www.g. MSc. BEng.org.g. or its equivalent in local currency. NVQ3 etc Course Title e. G Payment Options Subscription rates from 1 January 2012 until 31 December 2012 (Fees correct at time of print and subject to change in January 2013) Payment can be made by annual Direct Debit or one off Credit/Debit card please complete the relevant section overleaf.50 If your annual income from all sources is less than £24. Associate and Member Standard Rate: £129 Associate and Member Reduced Rate: £64. (if applicable): Address for Communication: County/State Telephone Email Address In my opinion this person has achieved the required knowledge and understanding and is a suitable candidate to become a Member of the IET and use the letters MIET* or TMIET* after their name (*please select as appropriate) Signature of Supporter Date Postcode Mobile Country dd / mm / yyyy The IET will contact your supporter for further background to your application for membership. 208925) affiliated to the IET. please tick the box to apply for a reduced subscription rate. Electrical Eng. Supporter’s Details: If you cannot find a suitable person to support your application. Your supporter can be your employer. responsibilities and other qualifications that are relevant to the interests of the IET. It is not IET policy to disclose comments made by supporters and we would urge applicants to discuss their membership application with the supporter prior to submission. a member of the IET or someone that knows you in a work capacity. . MIEAust: IET Membership No.Qualifications: Please provide details of engineering or technology qualifications you hold or are in the process of completing in the table below: Award/Course e.** **The IET reserves the right to verify your claim. please contact the Member and Customer Services Centre on +44 (0)1438 765678.org/membershipfees to find out about local currency rates. If you are applying from China or India please visit www.theiet. previous employment positions and any roles.ietconnect. IET Connect is the IET Benevolent Fund and asks all members to donate at least £7 with their IET subscription each year. 1 I would like to donate £7 or £ to IET Connect. MIMechE. please make it payable to the ‘Institution of Engineering and Technology’ and write your name and address on the reverse. First Name(s) Surname/Family Name Line Manager CEng IEng EngTech Job Title ICTTech Associate TMIET MIET FIET Please detail membership of other Institutions e. H Payment Amount Subscription fee £ Total £ 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. No.g.000. Alternatively you can pay by Sterling cheque/bank draft.

the Institution of Engineering and Technology will notify you 10 working days in advance of your account being debited or as otherwise agreed. Please also notify us of this. If you receive a refund you are not entitled to. ■ You can cancel a Direct Debit at any time by simply contacting your bank or building society. Herts SG1 2AY UK Name(s) of account holder(s) Service User Number 9 2 0 0 1 5 Reference (for office use only) Bank/Building Society Account Number Branch Sort Code Instruction to your Bank or Building Society. ■ If an error is made in the payment of your Direct Debit by the Institution of Engineering and Technology or your bank or building society. confirmation of the amount and date will be given to you at the time of the request. If you request the Institution of Engineering and Technology to collect a payment. details will be passed electronically to my Bank/Building Society. The Direct Debit guarantee ■ This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. Name and full postal address of your bank or building society To: The Manager Address Bank/Building Society Signature(s) Postcode Date Banks and building societies may not accept Direct Debit Instructions for some types of account. ■ If there are any changes to the amount. you must pay it back when the Institution of Engineering and Technology asks you to. The Institution of Engineering and Technology is registered as a Charity in England & Wales (no 211014) and Scotland (no SC038698) . Please pay the Institution of Engineering and Technology 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 of Engineering and Technology and. ✂ This guarantee should be detached and retained by the Payer. if so. date or frequency of your Direct Debit.Instruction to your bank or building society to pay by Direct Debit i Please fill in the whole form using a ball point pen and send to: Membership Application Team The IET Michael Faraday House Six Hills Way Stevenage. you are entitled to a full and immediate refund of the amount paid from your bank or building society. Written confirmation may be required.

The Institution of Engineering and Technology is registered as a Charity in England & Wales (no 211014) and Scotland (no SC038698) www.2 1 2 y y or Issue Number County/State Country The card holder’s telephone number and email address are required for any queries regarding processing the payment The card holder’s email address will be used to send a payment confirmation i Information Security Please do not submit your form by email.org .theiet.Credit/Debit Card Information Payment Amount £ Your name as it appears on the Credit/Debit Card Signature Please debit my (tick box as appropriate) Visa Visa Debit Visa Electron MasterCard Maestro JCB Solo American Express Date dd / mm / yyyy Credit/Debit Card Number Expiry Date m m / y y 3 or 4 digit security code Start Date m m / For Maestro or Solo cards only: Cardholder’s billing address Street Address City Zip/Postal Code Telephone Number of cardholder1 Email Address1. The IET takes the security of your personal details and credit/debit card information very seriously and will not process email transactions.