Illuminating Engineering Society of Australia and New Zealand Limited
ABN 99 100 686 039
Secretariat: PO Box 5059, DAISY HILL, QUEENSLAND, AUSTRALIA
Telephone +61 2 9431 8663 Facsimile +61 2 9431 8677
Email: Secretariat@iesanz.org    www.iesanz.org

 Please use the Tab key between entry Fields Do Not use the Enter key 
HIGHER MEMBERSHIP APPLICATION FORM
For the upgrade to Member (MIES) or Fellow (FIES)
Note: Applicants must complete three (3) copies of this Application Form. All sections must be fully completed by typing or legible hand-writing; reference to any previous application is insufficient. Please refer to Section 7 of the “IES Guide to Membership” for advice on how to complete this Application Form. Hard copies of the “IES Guide to Membership” are available from the Membership Secretary in your Chapter, or in electronic file (PDF) from the Society’s website at www.iesanz.org
For upgrade to “Technician” grade please use a separate special form available for this purpose.
PART 1 - PERSONAL DETAILS
Name:		Family:     		First & Second Name:     
Home		#/Street     			Suburb:     
Address:	State:     		Postcode:     		Country:     
Contact	Phone:     	Fax:     	Mobile:     

Details:	Email:     
		Date of Birth:  /  /    Year Joined IES:    Present membership Grade:      
Applying for upgrade to:	Member 	Fellow	
CURRENT EMPLOYMENT
Position:	Title or Description:     
Employer:	Company or Organisation:     
Work	#/Street     			Suburb:     
Address: 	State:     		Postcode:     		Country:     
			Phone:     	Fax:     	Mobile:     
			Email:      
DECLARATION BY APPLICANT
I declare that the particulars on this application are correct to the best of my knowledge and belief. If this application is accepted, I agree to abide by the Society’s Constitution, By-Laws and Code of Ethics.

____________________________________________	  /  /    

Signed							date:

PART 2 REFEREES
Please provide the name, address, membership grade, and if known the telephone/fax numbers, of three persons who have personal knowledge of the applicant’s work and who are willing to act as referee and to furnish a confidential report on this application. At least two of the referees should preferably, and in normal circumstances, be a Fellow or Member of the Society (please indicate referee’s grade below.) Persons of standing in other professional Institutions are also acceptable.
Please Note: The onus is on the Applicant to ensure that the Referee’s Report Forms, Application Forms, and sets of documents are returned by the Referees after completion, direct to the Secretary in the Applicant’s Chapter.

Name of Referee:	     		Member Grade:      
Address:		#/Street     			Suburb:     
			State:     		Postcode:     		Country:     
Contact		Phone:     	Fax:     	Mobile:     
Details:		Email:     

Name of Referee:	     		Member Grade:      
Address:		#/Street     			Suburb:     
			State:     		Postcode:     		Country:     
Contact		Phone:     	Fax:     	Mobile:     
Details:		Email:     

Name of Referee:	     		Member Grade:      
Address:		#/Street     			Suburb:     
			State:     		Postcode:     		Country:     
Contact		Phone:     	Fax:     	Mobile:     
Details:		Email:     

PART 3	GENERAL EDUCATIONS
(This Part need be completed only if no tertiary education and/or professional qualifications are to be reported in Part 5)
General education standard (give dates and examinations passed and only the highest level reached:
Year	School	Course Completed	Referee’s
Initials	
    	     	     	______	
    	     	     	______	
    	     	     	______	
    	     	     	______	
    	     	     	______	
    	     	     	______	
    	     	     	______	

Notes:
     
PART 4	EDUCATIONAL QUALIFICATIONS IN LIGHT OR LIGHTING
Lighting education (give full details of courses, dates and examinations passed) – include photocopies of all certificates gained and/or an official academic statement available from the appropriate educational institution – one set to be provided with each copy of the Application Form
Year	Institution	Course Title	Photocopy
Enclosed	
1999	     	     		
    	     	     		
    	     	     		
    	     	     		
    	     	     		
    	     	     		
    	     	     		

Notes:
     

PART 5 	TERTIARY EDUCATION and/or PROFESSIONAL QUALIFICATIONS
(other than Lighting Education) – include photocopies of all certificates and/or an official academic statement available from the appropriate education institution – one set to be provided with each copy of the Application Form
Year	Institution	Qualification Description	Photocopy
Enclosed	
1999	     	     		
    	     	     		
    	     	     		
    	     	     		
    	     	     		
    	     	     		
    	     	     		

Notes:
     

PART 6 ADDITIONAL EVIDENCE OF CONTRIBUTIONS TO LIGHTING
Contributions to the art, design, technology, science and practice of any aspect of lighting and/or to allied sciences, including original papers presented to the IES or kindred societies; design contributions to successful lighting awards; description of the nature and extent of service within the Society. A folio submission and presentation may also be accepted (please refer to the IES Guide to Membership available from the Chapter Secretary); etc. (Wherever possible please give full particulars and provide bibliography and/or copies of papers, include photocopies of certificates gained and provide other information with each Application Form in support of your case).
Indicate nature of contribution here, and add details on separate sheet(s):	Photocopy enclosed
     		
     		
     		
     		
     		
     		
     		
     		

PART 7 CONTINUING PROFESSIONAL DEVELOPMENT
Provide information on Continuing Professional Development, including: (a) number (approx) of IES Society meetings and IES Conferences/Conventions attended in past five years, (b) details of past or present service on Society committees etc, or any involvement in the Society or its activities if you reside in a remote location from a Chapter, (c) details of any similar involvement in any other professional organisation, (d) details of courses attended which constitute evidence of Continuing Professional Development. (Add separate sheet if insufficient space.)
Photocopy Verified

     		____	
     		____	
     		____	
     		____	
     		____	
     		____	
     		____	

PART 8 EMPLOYMENT RECORD
Give title or designation of positions held, general description of work involved, degree of responsibility and periods over which such experience was gained. Referee to certify with initials.

Years
(1998/00)	Organisation	Position Held	Description of Work	Referee’s
Initials	
     	     	     	     	_______	
     	     	     	     	_______	
     	     	     	     	_______	
     	     	     	     	_______	
     	     	     	     	_______	
     	     	     	     	_______	
     	     	     	     	_______	
     	     	     	     	_______	

Notes:
     

PART 9 APPROVED LIGHTING PRACTICE
Give details in clear unequivocal terms, so that the lighting practice, or work in allied fields associated with light, claimed under this Part, demonstrates that the work is directly related to and meets the professional practice requirements for transfer to a higher grade as described in the IES Guide to Membership, copies of which are available from the Secretary in your Chapter or the IES website www.iesanz.org

Dates
(1998/00)	Organisation	Description of work and aspects of project undertaken
	Referee’s
Initials	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	
     	     	     	_______	

Notes: