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 Employers 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 Ofce) to enable me to benet from the IET opportunities overseas. The benets of IET membership are enjoyed by our members globally. However if you do not wish to receive notication of IET products and services which may be of interest and benet to you (by post or electronic means) please tick this box. If you have a preference for receiving details of membership benets 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 conrm 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 nd 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 Qualications and Supporter Details sections) I wish to apply for Associate I  wish to apply for Member with the designatory letters TMIET (please complete the Qualications 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

Qualications:
Please provide details of engineering or technology qualications you hold or are in the process of completing in the table below: Award/Course e.g. BEng, MSc, NVQ3 etc Course Title e.g. Electrical Eng, 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, previous employment positions and any roles, responsibilities and other qualications that are relevant to the interests of the IET.

Supporters Details:
If you cannot nd 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 IET or someone that knows you in a work capacity. 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.g. MIMechE, MIEAust: IET Membership No. (if applicable): Address for Communication: County/State Postcode Country Mobile

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

dd / mm / yyyy

The IET will contact your supporter for further background to your application for membership. 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.

G Payment Options Subscription rates from 1 January 2012 until 31 December 2012
Associate and Member Standard Rate: 129 Associate and Member Reduced Rate: 64.50

(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. Alternatively you can pay by Sterling cheque/bank draft, please make it payable to the Institution of Engineering and Technology and write your name and address on the reverse.

If your annual income from all sources is less than 24,000, or its equivalent in local currency, please tick the box to apply for a reduced subscription rate.**
**The IET reserves the right to verify your claim.

If you are applying from China or India please visit www.theiet.org/membershipfees to nd out about local currency rates.

H Payment Amount
Subscription fee Total Please treat as Gift Aid donations all qualifying gifts of money made in the past 4 years, today and in the future.
I conrm I have paid or will pay an amount of UK Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities2 that I donate to will reclaim on my gifts for that tax year. I understand the charity will reclaim 25p of tax on every 1 that I give on or after 6 April 2008.

I would like to donate 7

or

to IET Connect, the IET Benevolent Fund1.

IET Connect is the IET Benevolent Fund and asks all members to donate at least 7 with their IET subscription each year. For more information on the services offered please visit www.ietconnect.org. The IET Benevolent Fund is a separately registered charity (Reg. No. 208925) afliated to the IET.
1 2

Including Community Amateur Sports Clubs

Instruction to your bank or building society to pay by Direct Debit

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Please ll in the whole form using a ball point pen and send to: Membership Application Team The IET Michael Faraday House Six Hills Way Stevenage, Herts SG1 2AY UK

Name(s) of account holder(s)

Service User Number

Reference (for ofce use only) Bank/Building Society Account Number

Branch Sort Code

Instruction to your Bank or Building Society. 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, if so, details will be passed electronically to my Bank/Building Society.

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.

This guarantee should be detached and retained by the Payer.

The Direct Debit guarantee

 This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. I f there are any changes to the amount, date or frequency of your Direct Debit, the Institution of Engineering and Technology will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request the Institution of Engineering and Technology to collect a payment, conrmation of the amount and date will be given to you at the time of the request. I f an error is made in the payment of your Direct Debit by the Institution of Engineering and Technology or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when the Institution of Engineering and Technology asks you to. Y  ou can cancel a Direct Debit at any time by simply contacting your bank or building society. Written conrmation may be required. Please also notify us of this.

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

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 /

3 or 4 digit security code Start Date m m /

For Maestro or Solo cards only: Cardholders billing address Street Address

or Issue Number

City Zip/Postal Code Telephone Number of cardholder1 Email Address1,2

1 2

County/State Country

The card holders telephone number and email address are required for any queries regarding processing the payment The card holders email address will be used to send a payment conrmation

Information Security Please do not submit your form by email. The IET takes the security of your personal details and credit/debit card information very seriously and will not process email transactions.

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

www.theiet.org