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Cchem Eligibility Form RSC

This document is an eligibility form for the award of Chartered Chemist. It requests information such as the applicant's membership details, qualifications, personal information, choice of CChem mentor, and payment details. The form notes that a CV must accompany the application and provides contact information for any questions. It also specifies that this form is to check eligibility and is not a full application for the Chartered Chemist award.

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Umang V Shah
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130 views3 pages

Cchem Eligibility Form RSC

This document is an eligibility form for the award of Chartered Chemist. It requests information such as the applicant's membership details, qualifications, personal information, choice of CChem mentor, and payment details. The form notes that a CV must accompany the application and provides contact information for any questions. It also specifies that this form is to check eligibility and is not a full application for the Chartered Chemist award.

Uploaded by

Umang V Shah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Eligibility form for the award

of Chartered Chemist
Office use

Membership number:

File Number:

Enclosures:

Before completing this form, please refer to the Requirements and information for applicants. A CV must
accompany your registration form. If you require any further advice please contact Membership Department.
Tel: +44 (0)1223 432141 email: [email protected] or visit the RSC website at www.rsc.org/careers/cpd/practising-scientists
Please note that this form is simply to check your eligibility to apply for CChem and is not a full application.

Please indicate whether you wish to register for:


Professional Development Programme (PDP)

Direct Programme

Direct Programme applicants require at least 6 years of appropriate postgraduate experience.

1. Current category of membership


Current category (please tick)

Member

Highest qualification

PhD

Fellow
MSc

Bsc

Other

(Please complete
Equivalence form)

(Please complete
Equivalence form)

Membership number
If you would like to receive information about becoming a Registered Scientist as an intermediary step, please tick this box.

2. Personal details
Title Miss

Family name

First name(s)

Mr

Mrs

Ms

Dr

Other (please specify)

Home address

Postcode

Telephone number
Email

Job title
Employers name
Employers address

Postcode

Email

Registered Charity Number: 207890


Job Number: 111334

3. CChem mentor
To be completed by the mentor. Please refer to Role and responsibilities of the mentor.
Name
Membership category
Job title
Work address

Postcode


Professional
relationship
to applicant

I have read the Role and responsibilities of the mentor and confirm that I understand and accept the requirements of the role.
Signature Date

4. CChem mentor choice


Please explain your choice of mentor and indicate how often you intend to discuss your CChem progress

5. Payment
For those registering for the Professional Development Programme, a registration fee of 25 must accompany this form.
For those registering for the Direct Programme, a combined registration and assessment fee of 50 must accompany this form.
Please note to enable your application to be processed, your payment will be banked on receipt.

Payment by credit card


Please charge my credit/debit card
Amount

Cardholders name
Card number
Valid from (MM/YY)
Expiry date (MM/YY)
Issue no.
Cardholders address (if different form section 2)

Cardholders signature Date

Payment by cheque
I enclose a cheque for 25 payable to the Royal Society of Chemistry. Please tick

6. Declaration
I, the undersigned, do hereby declare that, while a member of the Royal Society of Chemistry, I will observe the provisions
of the Charter and By-laws and any regulations made under them, and that I will conduct myself honourably in the practice
of my profession and will further the interests and maintain the dignity and welfare of the RSC for as long as I shall continue
to be a member. I certify that the information given on this form and in any attachments is correct to the best of my knowledge
and belief and that I will abide by the decision of the Council of the RSC in pursuance of this application. I understand and agree
that confirmation of information that I have provided will be sought and I hereby give permission for such information to be
processed by RSC in accordance with the data protection act and that such verifications may be made as deemed necessary.
Signature Date

Data Protection Act 1998 - The Royal Society of Chemistry will use the information you supply for the provision and administration
of its activities, products and services. Individual RSC members and prospective members have the right of access to the personal
data held on them by the RSC and the right to prevent its use for direct marketing purposes. The RSC does not disclose members
personal details to other organisations. It may, from time to time, execute mailings on behalf of suppliers of goods and services
considered to be relevant to your professional/scientific interests. If you do not wish to receive such information, please tick the box.
Enquiries relating to the Data Protection Act should be addressed to the Data Protection Officer at the address below.
Please return completed form to:
Membership Department, Royal Society of Chemistry, Thomas Graham House, Science Park, Milton Road, Cambridge CB4 0WF

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