Fellowship Application Form

Consent for storing submitted data *

Yes, I give permission to store and process my data

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First Name *

Surname *

Date of Birth *

Home Address including postcode *

Home Phone

Mobile

Home Email *

If you are upgrading your membership please state your current IPEM Membership Grade (leave blank if this is a new application)

Job Title *

Area of Work

Employer *

Work Address including department and postcode *

Work Phone

Work Email *

Phone number *

We need at least one phone number for you (mobile, home or work) as we might have to contact you about your application.

Please state which professional registration you hold. *

HCPC

RCT

AHCS

Engineering Council

Science Council

Chartered Physicist

International registration (state registration number and registration body)

I am employed in academia with a PhD

Please provide you registration number(s)

Organisation chart showing with your current position highlighted *

Current CV, maximum 5 pages *

Full list of research and other publications with my name highlighted

A report to justify your application structured according to the three eligibility criteria *

Verified copies of your educational certificates which have been signed by one of your Proposers OR provided contact details below of you head of department / line manager who can be contacted to confirm you educational qualifications.

New Applicants Only

Name of head of department / line manager

Organisation

Telephone

Email Address

IOP Registration Number (if applicable)

If you are also a member of the Institute of Physics (IOP) you are entitled to 25% discount on your membership fee. Please state your IOP membership category:

Once your membership application is approved we will contact you with instructions on how to pay your membership fee.

If you click "Next" and you are not taken to the next section it means that one or more of the above questions have not been answered. If you scroll back up red text will highlight what was missed.