Honorary Fellowship Nomination Form

Consent for storing submitted data *

Yes, I give permission to store and process my data

Name of Nominee *

Confirmation that this nominee is NOT a member of IPEM *

Confirmation that this nominee is NOT a member of IPEM

Nominee's address *

Including Postcode

Nominee's 'phone No *

Nominee's Email *

Nominator's address *

Include Postcode

Nominator's 'phone number *

Nominator's Email *

Please describe in up to 1000 words why this nominee should be awarded Honorary Fellowship (Individual Excellence) *

1 Individual Excellence and refer to guidance notes

Please describe in up to 1000 words why this nominee should be awarded Honorary Fellowship (Raising the profile of science or practice relevant to the IPEM charitable purpose. *

Raising the profile of science or practice relevant to the IPEM charitable purpose.

Please describe in up to 1000 words why this nominee should be awarded Honorary Fellowship (Developing Excellence) *

Developing Excellence

List and attach documents you wish to submit to support this nomination *

Please include the nominee's CV.

Nominator's Declaration: I confirm that the details given in this nomination are correct to the best of my knowledge. *

Nominator's Declaration: I confirm that the details given in this nomination are correct to the best of my knowledge.