CIPM - Memebership Application Form

Insert Your Passport Photograph Here

APPLICATION FORM FOR CIPMN MEMBERSHIP

Please complete every section of the form, If the space provided is insufficient, kindly write on a separate sheet of paper and attach to this form. All information contained herein will be kept in strictest confidence.

Please forward your printout to:
The Registrar, Chartered Institute of Personnel Management
CIPM House, CIPM Avenue, Alausa Ikeja, Lagos, Nigeria

Please tick accordingly

Individual Membership Application

Corporate Nominee Application

PERSONAL PARTICULARS
Title
Surname
Other names
Marital Status
Date of Birth	(dd/mm/yyyy)
Local Government Area
State of Origin
Correspondence Address
Tel No.
Mobile phone
Email
Nationality
Residential Address
Residential Phone

EDUCATIONAL QUALIFICATIONS
(Attach photocopies of Certificates including ordinary Level)

QUALIFICATION	INSTITUTION ATTENDED	DATE

PROFESSIONAL MEMBERSHIP
(Attach photocopies of Certificates)

NAME of PROFESSIONAL BODY	GRADE OF MEMBERSHIP	DATE OF ELECTION

JOB HISTORY

NAME & ADDR OF ORGANIZATION	DATE FROM - TO	POSITION HELD

PRESENT EMPLOYER
Name
Address
Tel No.
Fax No.
Email
Nature of Business
Total number of employees		Junior Senior
Last year's Revenue/Turnover (if Known)

POSITION IN PRESENT EMPLOYMENT:
Title or Designation
Date of Appointment to Present position
The scope & nature of present duties

PROFESSIONAL TRAINING COURSES ATTENDED

DECLARATION BY APPLICANT

I, declare that the statements made herein are correct to the best of my knowledge and belief, and that I agree to be governed by the enabling Decree, any Bye-Law / Regulation and code of conduct of the Chartered Institute of Personnel Management of Nigeria, as they now exit and as they may from time be enacted.

CERTIFICATION BY IMMEDIATE SUPERIOR OF THE APPLICANT OR HEAD OF HUMAN RESOURCES OF HIS/HER ORGANISATION
I hereby certify that the particulars given is true and correct to the best of my knowledge and belief.

Name		Organization
Address		Position

____________________
Signature

official stamp

____________________
Date

SPONSOR (A FINANCIAL MEMBER OF THE INSTITUTE)

Name
Membership grade & No
Organization

_________________ Signature		____________________ Date

FORM FEE & DOCUMENTS REQUIRED
Form Fee	=N=3000.00
All monies payable in the Institute’s favour can be made at any branch of United Bank for Africa (UBA) Plc on A/c. No. 2182010000887 or Intercontinental Bank Plc A/c. No. 0004-001-000005078. The deposit tellers must be forwarded to the National Secretariat with the name, payment purpose, membership grade and branch (for members only) clearly indicated overleaf.
On Submission of form the following are needed: Photocopies of Receipt Photocopies of Certificate(GCE/WAEC,First Degree etc) and Transcripts. Copy of NYSC Certificate. Marriage Certificate Newspaper Advert indicating "Change of Name" Copy of CV/Resume
FOR OFFICIAL USE ONLY Eligible: [ ] Not- Eligible:[ ] Receipt No: ____________________________________ Date Received: __________________________________ Date Registered: _________________________________ Form Processed by: _______________________________