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Application for IPEM Full Membership
Institute of Physics and Engineering in Medicine
Job title
Employer
New application
Transfer
Title First Name(s)
Surname
DD/MM/YYYY
Home Address
Work Address (including department)
Mobile
Telephone
Post Code
Please send correspondence to:
Mobile
Telephone
Post Code
Work AddressHome Address
Date of Birth
Issue Date: November 2014 Revised by: Office
Original Issue Date: 22-10-2003
Page 1 of 2 (03-06-01)
Document Number: 0048 Version Number: 06.00
Gender
Confirmation of Education and Training
I have asked the following IPEM Fellow, Member or my line manager to verify my education and training certificates.
If you are transferring please enter your membership number
Title
Name
Membership number if applicable
Job Title
If you are a on a Statutory or Voluntary Register, please state which:
Your Registration Number:
Application for IPEM Full Membership
Institute of Physics and Engineering in Medicine
Please sign and send completed form to: Membership Department, IPEM, Fairmount House, 230 Tadcaster Road, York, YO24 1ES
or email to [email protected]
Page 2
Declaration I wish to apply for Membership of the Institute of Physics & Engineering in Medicine and declare that the information I have given in this application is, to the best of my knowledge, accurate and true. I agree to be governed by the Rules of IPEM, including its Code of Professional Conduct, and accept that any breaches of the Rules or the Code of Professional Conduct will be dealt with under IPEM's Disciplinary Procedure.
Date
Signed the application form (below)
Enclosed the Report of Training and Experience
Enclosed verified copies of educational and training certificates
Check List I have:
Signature
When applying for Full Membership you can request further information about the following Awards: Full details will be sent to you via email. CSci or CEng orRSci IEng
If you are also a member of the Institue of Physics (IOP) you are entitled to 25% discount on your membership fee. Please state your IOP membership category:
Your IOP Registration Number:
