CSci Application

Personal Information

Consent for storing submitted data *

Yes, I give permission to store and process my data

See our Privacy Policy listed on our website.

First Name(s) *

Last Name *

Date of Birth

Home Address

Including postcode

Home Phone

Home Email *

Professional Information

Work address

Including dept (if applicable) postcode

Work Phone

Work Email

Academic Qualifications

Institution

Qualification

Subjects

Class/Grade

If applicable

Additional Qualification 1

Institution

Qualification

Subjects

Class/Grade

If applicable

Additional Qualification 2

Institution

Qualification

Subjects

Class/Grade

If applicable

Additional Qualification 3

Institution

Qualification

Subjects

Class/Grade

If applicable

Other memberships and registrations

IPEM Membership Number *

Date joined

If known

Existing designations (eg EngTech):

Membership of other professional or learned bodies

Supporter Details

First Name

Surname

Registration type and number

Additional information and supporting documents

Please upload any additional documents you wish to provide to support your application (e.g ENIC statement)

Declaration

I wish to apply for registration, via IPEM, as a Chartered Scientist and declare that the information I have given in this application is, to the best of my knowledge, accurate and true. I agree to maintain my competence through continuing professional development (CPD) by participating in IPEM’s CPD scheme, making an annual declaration of my CPD activity and making my full CPD record available for audit whenever required. I also agree to observe the Code of Professional and Ethical Conduct issued by IPEM and accept that any breaches of the Rules of Professional and Ethical Conduct will be dealt with under IPEM’s disciplinary procedures.

Signed