iema
Affiliate
For office use only Reference
INSTITUTE OF ENVIRONMENTAL MANAGEMENT & ASSESSMENT
Membership Application Form
Membership level you are applying for:
* Please provide evidence of your Student/Graduate status (e.g. NUS Card/enrolment card/letter/transcript of results etc)
Student*
Graduate*
Personal Details
* Mandatory fields
PLEASE COMPLETE THIS FORM USING BLOCK CAPITALS
Title Mr /Miss/Mrs/Dr * (delete as appropriate) Main/Home Address* Job Title
Forename*
Surname*
Telephone* E-mail*
Postcode*
Mobile*
Date of Birth
Work/Term Address
(if different from Main/Home Address)
Organisation/University/College Telephone E-mail Postcode Mobile
Preferred postal contact address
Main/Home
Work/Term
How did you hear about the IEMA in the first instance? Advertisement/Leaflet Please specify
Background Information
Conference/Exhibition Please specify Training Course Please specify Word of mouth Referral by a current member
Please indicate your occupational sector (tick one as the most applicable) C. Manufacturing A. Agriculture, forestry & fishing B. Mining & Quarrying F. Construction D. Electricity, gas, steam and air conditioning supply
IEMA website/E-mail
E. Water supply, sewerage, waste & remediation G. Wholesale and retail trade I. Accommodation and food services
H. Transport and storage L. Real Estate services
M. Professional, scientific and technical services Q.Human health and Social Work services U. Activities of extraterratorial organisations Environmental Management Systems (EMS) S. Other services O. Public administration and defence
K. Financial and insurance services
J. Information and Communication
N. Administrative and support services P. Education R. Arts, Entertainment and Recreation
T. Activities of households as employer
Please indicate your areas of responsibility or interest (tick as many as are applicable) Environmental Impact Assessment (EIA) Sustainability/CSR Energy Environmental Management Integrated Management
Strategic Environmental Assessment (SEA)
Waste
Contaminated Land Change Pollution Control Climate Change
Auditing/Verification/Assurance
Environmental Law/Legislation
Environmental Training Air Quality Environmental Health
Risk Assessment
Acoustics/Noise/Vibration Land Use/Planning Research Water
Ecology/Biodiversity/Wildlife
Recycling
Transport
Other (please specify)
Equal Opportunities
The details on this form will be logged anonymously and will be treated in the strictest confidence. Gender
Please help us to monitor our membership and deliver the best possible service to you.
Male
Female
Age
45 - 54
Under 21
55 - 64
21 - 24
65 - 74
24 - 34
Over 75
35 - 44
Are you registered disabled? Yes No
Ethnic Origin Please indicate how you would prefer to describe your ethnic origin by ticking the most relevant category. White Mixed
British Other
White and Black Caribbean White and Black African White and Asian
Other Asian and Asian British Indian Pakistani
Black and Black British Caribbean African Other
Other Chinese
Bangladeshi
Chinese Other
By completing this form I understand that I give my consent under the Data Protection Act 1998 for the information contained in this form to be processed in accordance with the IEMA policy for the purposes of equal opportunities monitoring.
Visit www.iema.net/membership for up-to-date membership subscription fees.
PLEASE COMPLETE THIS SECTION USING BLOCK CAPITALS
Payment Details
Credit/Debit Card
For office use only Membership number
Please charge (delete as applicable) Visa Credit/Debit /
to my credit/debit card for my Affiliate / Student / Graduate membership Mastercard Expiry date Delta / Solo Issue number Maestro
Card number Start date
Cardholders name (please write this exactly as it appears on the card) Cardholder/Billing Address
Security number* (last three digits located near the signature strip on the back of the card)
Postcode Cheque I enclose a cheque for membership (delete as applicable) made payable to the IEMA for my Affiliate / Student / Graduate
By signing this application form you accept that all or part of the information provided on this form may be used and processed by the IEMA for membership administration, fulfilling the aims of the IEMA and compliance with the IEMAs statutory obligations. Such use will be in accordance with the provisions of the Data Protection Act 1998.
Data Protection Policy
Signature Please return this form to: Institute of Environmental Management & Assessment St. Nicholas House 70 Newport Lincoln LN1 3DP UK Tel: +44 (0)1522 540069 Fax: +44 (0)1522 540090 E-mail: info@iema.net Website: www.iema.net
Date
