Illuminating Engineering Society of Australia and New Zealand Limited
ABN 99 100 686 039
Secretariat: PO Box 576 Crows Nest NSW 1585 AUSTRALIA
Telephone +61 2 9431 8663 Facsimile +61 2 9431 8677
Email: Secretariat@iesanz.org    www.iesanz.org

MEMBERSHIP UPGRADE FORM - Technician
MEMBER DETAILS

FAMILY NAME:		     	
GIVEN NAMES:		     
ADDRESS (Home):		(#/Street:)     		(suburb:)     
				(State:)      		(Postcode:)      	(Country:)     
PHONE (Home):	     	Mobile:      
E-MAIL (Home):	     
DATE of BIRTH: 	  /  /    
EMPLOYER/COMPANY: 
ADDRESS (Work):		(#/Street:)     		(suburb:)     
				(State:)      		(Postcode:)      	(Country:)     
PHONE (Work):	     	Mobile:      
E-MAIL (Work): 	     
COURSE DETAILS
NAME OF COURSE COMPLETED:	     
NAME OF EDUCATIONAL INSTITUTION :	     
DATE(S) OF COMPLETION OF CERTIFICATE:		     -     
TECHNICIAN MEMBERSHIP

I hereby apply for upgrade to “Technician” grade Membership of the Illuminating Engineering Society of Australia and New Zealand Limited and agree to adhere to the Society’s Constitution, By-Laws and Code of Ethics. I have attached a copy of my Tertiary institution Certificate indicating my completion of the appropriate Illumination course as set out in the Society’s “Guide to Membership”.
APPLICANT’S
SIGNATURE:	DATE:  /  /    

Application received by Chapter			
(including sighting of certificate) on:	___ / ___	/	
Application forwarded to Secretariat on:	___ / ___	/	
Application approved by the Board on:	___ / ___	/	
Letter of Acceptance posted on:	___ / ___	/	
New Membership Certificate posted to CMC on:	___ / ___	/	
Membership No.:			

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OFFICE USE ONLY