Institute of Physics and Engineering in Medicine

Application for Membership

New application
Category Transfer

When applying, for some categories, you can also apply for additional Awards:
PLEASE READ THE GUIDELINES
FOR MEMBERSHIP BEFORE Corporate Membership: CSci and/or CEng
COMPLETING THIS APPLICATION Incorporated Membership: CSci and/or IEng
Associate Membership: EngTech

Title First Name(s) Date of Birth

DD/MM/YYYY
Surname
Other (Please specify)

Work Address
Home Address (including
department)

Post Code Post Code

Telephone Telephone

Fax Fax

Email Email

Send mail to: Home Address Work Address

Certificate or Diploma First Degree Higher Degree Doctorate

Institution

Qualification

Subject(s)

Class

Year

Additional
Information

Thesis titles, project reports, publications & other professional membership

(if necessary, continue on a separate sheet, clearly labelled with your name and continuation point) HPC Registration Number:

Present Appointment Employer

Current Grade Date Appointed Specialist Area

DD/MM/YYYY
Which classification best describes your appointment?

NHS Medical Physicist University Physicist Physicist in Industry Other (Please Specify)

NHS Clinical Engineer University Engineer Engineer in Industry

 Institute of Physics and Engineering in Medicine

Application for Membership

Page 2

ORGANISATION CHART
Draw an organisation chart for your present post, showing the line management structure immediately above and below you, and colleagues working
alongside you. Each post shown should be labelled with the name, initials and qualifications of the post holder, and your own post should be clearly marked,
giving the number of persons directly supervised by you where this is not clear from the chart. You may also provide not more than two organisation charts
relating to previous posts, which relate to the responsible experience being offered.

REPORTS OF TRAINING AND RESPONSIBLE EXPERIENCE

In a comprehensive CV give details of formal work-based training you have received from an accredited training provider if applicable giving start and finish
dates, credentials of training provider and the scientific/engineering content of the training. Also set out, in chronological order, the dates and designations
of all posts held, giving with each one the name of the employer, the place of employment, and a brief description of your duties and responsibilities, which
will inform the Membership Panel of your personal contribution and the way in which you have applied your scientific/engineering education, training and
experience.
Please ensure that organisation charts and statements of training and responsible experience contain your name and are cross referenced to this application.

APPLICANT'S UNDERTAKINGS
I wish to apply for Membership of the Institute of Physics & Engineering in Medicine in the category indicated on page 1 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 the IPEM,
including its Code of Professional Conduct, and accept that any breaches of the Rules or the Code of Pofessional Conduct will be dealt with under
the IPEM's Disciplinary Procedure.

Signature of Applicant Date

Proposers & Supporters

Proposers SHOULD, whenever possible, be Fellows, Corporate Members or Incorporated Members of IPEM . In addition applicants for CEng registration
must be proposed by Chartered Engineers and applicants for IEng registration by Chartered or Incorporated Engineers.
We, the undersigned, propose the candidate, from personal knowledge, as a person worthy of consideration for Membership of IPEM in the grade
for which application is made. We endorse the accuracy of those parts of the application we have verified by our initials, reference sets of which are
given with our signatures.

Proposer 1 Title Other Proposer 2 Title Other

Name Name

Work Work
Address Address

Professional Qualifications Professional Qualifications

Signature (Proposer 1) Signature (Proposer 2)

Initials Date Initials Date

Additional supporters should be given where Proposers 1 and 2 alone cannot verify all the information given in this application.
Details of additional supporters, in the form above, should be given on a separate sheet. Supporters who are not Members of the IPEM should
indicate of which Professional Institutes they are Members.

For Engineer Registration applications, only when prior approval of educational qualifications has been given:
Date of preliminary Registration Engineering Council Reference Number
DD/MM/YYYY

For office use only Date Received Acknowledge Ref. No.

List. No. Qualifications Decision Notification

Please send completed form to:

Print Form Membership Registrar, IPEM, Fairmount House, 230 Tadcaster Road, York, YO24 1ES