APPLICATION FOR MEMBER/FELLOW OF CIBSE

Please tick as appropriate

MCIBSE

FCIBSE
Please indicate whether
New
(not previously a member of CIBSE) or
!ransfer (already
CIBSE member)
"embership#
No $rade
%ave you previously applied to &oin the CIBSE' (state Y/N in the bo()
)lready CEn* +e*istered' (state Y/N in the bo()# If yes please *ive +e*istration number
and the Institution throu*h which you are +e*istered# Please attach proof of +e*istration#
Proof attached Yes/No (delete as appropriate)
,# PERSONAL DETAILS
Surname -irst Names !itle
.ate of Birth (../""/00)
(tick bo( for preferred contact address)
Private Address Business Address
Company name
Post Code Post Code
!el -a( !el -a(
email email
"obile
Please tic !ere i" #ou do not $is! to receive e%ternal &ail
Please su'&it ( !ard co)ies in total PL*S a CD Ro& version o" t!is "or& and all su))ortin+
docu&entation,
-!at )ro&)ted #ou to su'&it t!is a))lication. Select ONE onl#/ CIBSE 01 use onl#/
Contacted by CIBSE
)dvised by collea*ue/boss
)ttended a membership briefin* session
1ooked at the CIBSE website
)pproached at a CIBSE event
Saw article/advert in industry publication
, of 2 "CIBSE or -CIBSE 3 4ersion ,5/ .ate of issue6 7une 89,8
CIBSE *se Onl#
Batch No# #::::::###:::#
)mount :::::::##:#::#
.ate ::::::::#:##::##
"embership No## ::##:::::
EN;6 ::::::::::::
Code/ PD2-EB
3, ED*CATIONAL 1*ALIFICATIONS 4Please list all #our )ost sc!ool 5uali"ications and indicate an# e%e&)tions +ranted and details o"
an# interru)tions to #our course6, A$ards s!o$n &ust 'e acco&)anied '# a )!otoco)# o" t!e ori+inal certi"icate countersi+ned '# #our
S)onsor as !avin+ seen t!e ori+inal6
*niversit# or Colle+e Full title o" 5uali"ications
+ained includin+ su'7ect area
Date course
co&&enced
Course
duration
Date
5uali"ication
o'tained
Mode o" Stud#
4F/T8 P/T8
sand$ic!8 etc,6 9
<-/! = full time P/! = part time
> EMPLOYMENT DETAILS
Please append a typewritten curriculum vitae providin* full details of your work e(perience within the field of buildin* services en*ineerin*6 with
dates full details of the companies you have worked for the posts you have held and level of responsibility#
: EN;INEERIN; PRACTICE REPORT
Ne$ a))licants/ Please append a completed En+ineerin+ Practice Re)ort of appro(imately ?999 words# 0our +eport should be based on the
Competence Criteria for "CIBSE/-CIBSE (fact sheet M21/F21). It should include a brief introduction and be countersi*ned by your Sponsor#
)dvice on how to put to*ether your +eport is in fact sheet M20/F20.
A))licants trans"errin+ "ro& Me&'er to Fello$ / Separate form available
Please indicate if you have followed a CIBSE approved trainin* pro*ramme 0ES N@
< OR;ANISATIONAL C0ART
Please append a chart indicatin* your position in the or*anisation#
= DE>ELOPMENT ACTION PLAN
)ll those wishin* to &oin CIBSE are reAuired to show commitment to maintainin* their professional capabilities and knowled*e# Please a))end
#our Develo)&ent Action Plan statin+ #our s!ort8 &ediu& and lon+ ter& +oals and #our intended actions to attain t!ose +oals, See "act
s!eets M3? 4"or Me&'er6 or F3? 4"or Fello$6
@ MAIN EN;INEERIN; DISCIPLINE
Please indicate from the list below your main area of e(pertise in buildin* services en*ineerin*# !his information will assist CIBSE in allocatin* an
appropriate assessor to appraise your application#
Acade&ia Electrica
l
Ener+#
Mana+e&ent
Environ&enta
l
Facilities
Mana+e&ent
M A E Mec!anica
l
Pu'lic
0ealt!
Ot!e
r
If you have ticked Other please specify6
B INTER>IE-
Please circle8 or indicate clearl#8 #our )re"erred location and $e $ill tae t!is into account $!en arran+in+ #our intervie$,
Nort! -est Sout! -est London and
Sout! East
Nort! East Scotland East
Midlands
-est
Midlands
8 of 2 "CIBSE or -CIBSE 3 4ersion ,5/ .ate of issue6 7une 89,8
Yors!ire -ales Nort!ern
Ireland
Ireland 0on+ Con+ Australia *nited Ara'
E&irates
1atar
D SPONSOR
All applicants must provide one sponsor, who is F!"#$, M!"#$ or re%istered $n% with an& $n%ineerin% ouncil 'ominated !nstitution or
professionall& re%istered within the construction industr&. (he sponsor should have )nown &ou for a minimum of one &ear.
SPONSORS DECLARATION
I confirm that I have known the applicant for a minimum of one year# !o the best of my knowled*e all the information contained in this application
and supportin* documents is correct# I confirm that I have seen the ori*inal Aualification certificates referred to in the application and have initialled
photocopies of them#
I confirm my support for this application at the *rade applied for#
Si*ned ::::::::::::::# Print Name ::::::::::::::::::::## .ate ::::::#
)ddress ::::::::::::::::::::::::::## !elephone ::::::::::::::::
::::::::::::::::::::::::::## "obile ::::::::::::::::
::::::::::::::::::::::::::## Email ::::::::::::::::
::::::::::::::::::::::::::## Post Code ::::::::::::::::
Institution &e&'ers!i)/
Name of Institution6 ::::::::::::::::::::::##
EC re*istration *rade :::::::: Bnown applicant :::# years
If you are professionally re*istered with a non3En*ineerin* Council nominated institution please send a copy of your re*istration certificate with this
application#
NB# #ponsors ma& *e contacted *& !"#$ for confirmation of their support of the applicant. #hould sponsors wish to provide additional information
to the !nstitution the& can do so *& correspondin% directl& with the Mem*ership Officer at !"#$.
E? APPLICANTFS DECLARATION
I certify that the information contained in this application and supportin* documents is correct# I a*ree that in the event of my election to any class
of membership of the Chartered Institution of Buildin* Services En*ineers I will be *overned by the provisions of the +oyal Charter and By3laws as
they are now formed or as they may be hereafter alteredC that I a*ree to abide by the Code of Professional Conduct and do all in my power to
advance the ob&ects of the InstitutionC providin* that whenever I shall si*nify in writin* to the Secretary that I wish to withdraw from the Institution I
shall after payment of any arrears which may be due by me at that period be free from this obli*ation#
Si+ned :::::::::::::::::::::::::::::## Date ::::::::::::::::
NB, In the event of it coming to light tht info!mtion "#$$lie% on thi" fo!m i" incc#!te& CIBSE !e"e!ve the !ight to 'ith%!' mem(e!"hi$ of
the In"tit#tion n% %i"ci$line the $$licnt #n%e! the Co%e of P!ofe""ionl Con%#ct)
CIBSE seeks to provide the best possible support to candidates# -rom time to time we use applicantsD material to illustrate best practice#
I" #ou do not $is! #our a))lication to 'e used "or t!is )ur)ose8 )lease tic !ere
!hank you for helpin* us help othersE
NB6 0our name and contact/payment details will not be divul*ed#
> of 2 "CIBSE or -CIBSE 3 4ersion ,5/ .ate of issue6 7une 89,8
EE FEES Please send appropriate fees with this application (e(cludin* annual subscription)# See Fct Sheet I*+ "or details o" A))lication Fee and
ot!er "ees# CheAues should be made payable to CIBSE or by credit card below
* Payment attached / please debit my:
MasterCard
Vis
a
Visa
Delta
Switch
With _____________
Cardholders Name: ________________________________________________
Card
Nmber:
Card !"piry
Date:
/ Card Start
Date:
/
Secrity Code: #sse No $i%
applicable:
$&ast ' di(its on the re)erse o% the card*
Cardholders si(natre: _________________________________________________
Cardholders address+ incldin( %ll postal code
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* Delete where appropriate,
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FOR OFFICIAL *SE ONLY
)pplication
-ee
Paid
P+/C+ -ee Paid
EC ;ualification Code (if any)
CIBSE Panel "eetin* .ate .ecision6
+e*istration Panel "eetin* .ate .ecision6

ICP No# 0ES N@ Decision
? of 2 "CIBSE or -CIBSE 3 4ersion ,5/ .ate of issue6 7une 89,8
Please return to/ Me&'ers!i) De)art&ent
C0ARTERED INSTIT*TION OF B*ILDIN; SER>ICES EN;INEERS
Incor)orated '# Ro#al C!arter ED@= Re+istered C!arit# No, 3@BE?:
333 Bal!a& 0i+! Road8 London8 S-E3 DBS Tele)!one ?3? B=@< <3EE
Fa% ?3? B=@< <::D
2 of 2 "CIBSE or -CIBSE 3 4ersion ,5/ .ate of issue6 7une 89,8