CIPM - PCP/APCP Application Form

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Application form for PCP/ APCP

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. The Form should be filled in CAPITAL LETTERS.

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

Please tick accordingly

Professional Certification Programme
    Recruitment, Selection & Placement
    Industrial and Employee Relations
    Performance Management

Accelerated Professional Conversion Programme

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

COMPANY'S PARTICULARS
Name
Address
Tel No.
Fax No.
Email
Nature of Business

Position in Present Employment:
Title or Designation
Date of Appointment to Present position
The scope & nature of present duties

ACADEMIC/SPECIALISED QUALIFICATIONS/COMPETENCIES

Please indicate below:

Year
School/Institution
Highest Qualification/Competencies Attained
Any Additional Information

WORKING EXPERIENCE

Please indicate below:

Year (From)
Year (To)
Designation
Company
Responsibility/Duties

Other Professional Membership

Please indicate below:

Year
Professional Organisation
Category of Membership

DECLARATION BY APPLICANT
I, declare that the Statement made herein are correct to the best of my knowledge and belief, and I agrees to be governed by the Enabling Decree, any Bye - Law / regulation and code of conduct of the Institute of the Personnel Management of Nigeria, as they now exist and as they may from time to time be enacted.

______________________________________ Signature	__________________________________ Date

CERTIFICATION BY IMMEDIATE SUPERIOR OF THE APPLICANT OR HEAD OF HUMAN RESOURCES OF YOUR ORGANISATION OR ANY OTHER REFEREE
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

FORM FEE & DOCUMENTS REQUIRED
Form Fee	=N=2500.00
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.
Copy of CV/Resume (bearing details of work experience) Copy of CIPM Membership Certificate or Letter of enrolment
For Official Use Ratings - Date Received: ____________ Receipt No: __________________ Date Registered: ________________________________ Registration Number: _____________________________ Module / Course: ________________________________