APPLICATION FOR ASSESSED MEMBERSHIP
HOW TO USE THIS FORM You can use this Application Form to apply for or upgrade your personal membership of the Institute of Interim Management (the “Institute”).
This Application Form is in Word format and you are encouraged to complete it as a document edit and submit it as an email attachment, together with electronic copies of all other supporting documentation. However, it may also be completed by typing/handwriting the information in on a hard copy, and posted. If handwriting, please do so clearly in block capitals and black ink. If there is insufficient space in any part of the Form to fill all relevant details, please continue on separate sheet(s).
Explanatory Notes to accompany this Application Form are available to download from the Institute’s web site www.ioim.org.uk, or can be obtained from the Membership Assessment Committee at the address at the foot of this page. You are urged to obtain and read these Explanatory Notes before filling out this Application Form.
Please retain a copy of the completed Application Form to refer to if you are contacted for additional information.
If assistance is required on how to complete this Form, please e-mail [email protected], or telephone +44 (0) 870 242 0814.
COMPLETION CHECK LIST The Membership Committee will process your application as quickly as possible, on receipt. You can help this process by ensuring that you submit copies of all the documentation required by the Committee, and the following checklist should assist you to do so.
Documentation to be submitted Y/N
1 The completed application form (including any continuation sheets) Re Section 2, electronic / photo copies of: Certificate of Incorporation 2 VAT Registration Promotional Literature Re Section 3, electronic copies or photocopies of all: 3 Degrees Professional Qualifications Re Section 5, electronic copies or photocopies of: 4 Your current full CV Other supporting documents (especially re interim assignments)
Please indicate (X) Sterling Euro Please indicate how you will be paying the By cheque made payable to IOIM Ltd Assessment Fee in connection with this Application (see next page). By direct electronic credit
SUBMITTING YOUR APPLICATION The completed Application Form and electronic / photo copies of all supporting documentation should be returned as follows:
By Email: By Post: The Membership Assessment Committee The Membership Assessment Committee at Dolphins, Elmstead Road West Byfleet Surrey KT14 6JB [email protected] United Kingdom
A Company Limited by Guarantee, Registered in England and Wales, No 4589083 Registered Office: Dolphins, Elmstead Road, West Byfleet, Surrey KT14 6JB AF.MGM.1004 PAYING THE ASSESSMENT FEE
The Institute does not currently offer the facility for you to pay your Assessment Fee by credit or debit card. Payment can only be made by cheque sent by post, or by direct electronic credit to the Institute’s bank account. Please indicate on the previous page which payment method you will be using, so that consideration of your application is not delayed because of difficulty in identifying your remittance.
By Cheque:
Cheques should be drawn in Sterling on a UK bank, or in Euros drawn on a ‘Eurozone’ bank. In either case, the cheque should be made payable to IOIM Ltd and should be sent by post to: The Secretary Dolphins, Elmstead Road West Byfleet Surrey KT14 6JB United Kingdom
Please print your name and address on the back of the cheque. By direct Electronic Credit: In Sterling: In Euros: HSBC HSBC 69 Pall Mall International Branch St James's PO Box 181 London SW1Y 5EY 27-32 Poultry London EC2P 2BX Sort Code: 40-05-20 Account No: 11407171 Sort Code: 40-05-15 Account Name: IOIM Ltd Account No: 58917198 Account Name: IOIM Ltd IBAN No: GB32MIDL40052011407171 IBAN No: GB54MIDL40051558917198 SWIFT BIC: MIDLGB2107 SWIFT BIC: MIDLGB22
OTHER INFORMATION
How did you hear about the Institute of Interim Management?
IIM Member (see also below)
IIM Web Site
Other professional bodies/associations – please name organisation(s)
Interim Provider or other ‘Intermediary’ – please name company(ies)
Outplacement agency – please name company(ies)
InterIM Insight (IIM Newsletter)
Advertising/Trade Journals/Press Release
Other (please specify)
Member Name Member No Are you being introduced by an existing IIM member? If yes, please give his/her name and membership number.
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AF.MGM.1004 SECTION 1 – ABOUT YOU & YOUR INTERIM PRACTICE
ABOUT YOU ABOUT YOUR INTERIM PRACTICE
Title Company/Trading Name (Mr, Mrs, Ms, Other) Company Type Surname (Sole trader / partnership / LLP / company)
Known As Date Practice Commenced
Forenames Date of Incorporation (in full) (if a company)
Date of Birth Registered number (dd/mm/yy) (if a company)
Gender VAT Registration number (M /(F) (if practice registered)
SECTION 2 – ADDRESSES & CONTACT DETAILS
YOUR INTERIM PRACTICE HOME (if different from HOME) Address – Line 1
Address – Line 2
Address – Line 3
Town/City
County
Post Code
Country
Telephone
Fax
Mobile
E-mail (1)
E-mail (2) Website address (http://www.) Please indicate (X) your preferred contact point for communications from the Institute YOUR INTERIM HOME PRACTICE
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AF.MGM.1004 SECTION 3 – QUALIFICATIONS
3.1 Management Qualifications Course Title Awarding Organisation Grade Year
3.2 Non-Management Degrees Course Title Awarding Organisation Grade Year
3.3 Qualifications being undertaken (please indicate expected completion date) Course Title Awarding Organisation Year
3.4 Professional Qualifications (awarded by examination) Course Title Awarding Organisation Grade Year
3.5 Membership of other Professional Organisations Name of Organisation Grade Membership No. Date Awarded
3.6 Other Skills/Experience
International Experience: (by country)
Languages: (please indicate proficiency (X)) Fluent Intermediate Basic
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AF.MGM.1004 Please submit a photocopy of all degrees and professional qualifications listed above.
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AF.MGM.1004 SECTION 4 – REFERENCES 1st Referee 2nd Referee Name: Name: Title: Title: Organisation: Organisation:
Address: Address:
Post Code: Post Code: Telephone: Telephone: E-mail: E-mail:
Both referees should have detailed knowledge of the applicant in a business context. If details of Interim assignments are listed in SECTION 5 – CAREER DETAILS, the 1st Referee should be able to vouch for at least one of the current or recent assignments listed.
SECTION 5 – CAREER DETAILS 5.1 Pre-Interim Career Please provide details of your full time positions in reverse chronological order. The details given should be supported by a copy of your full CV, identifying responsibilities and achievements.
(1) Organisation Name Date From Date To Job Title Nature of Business No of employees | of which directly managed Other resources managed Value of budget/portfolio managed Reporting to (job title) (2) Organisation Name Date From Date To Job Title Nature of Business No of employees | of which directly managed Other resources managed Value of budget/portfolio managed Reporting to (job title) (3) Organisation Name Date From Date To Job Title Nature of Business No of employees | of which directly managed Other resources managed Value of budget/portfolio managed Reporting to (job title)
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AF.MGM.1004 SECTION 5 – CAREER DETAILS (continued)
5.2 Interim Assignment Details Please provide details of your Interim positions in reverse chronological order. Please include with your application your full CV and any documents that will help the assessors to reach an understanding of the seniority, scope and success of these assignments.
(1) Client Organisation Name Date From Date To Nature of Client’s Business Interim Title Nature of Assignment Length of Assignment No of employees | of which directly managed Value of budget/portfolio managed
(2) Client Organisation Name Date From Date To Nature of Client’s Business Interim Title Nature of Assignment Length of Assignment No of employees | of which directly managed Value of budget/portfolio managed
(3) Client Organisation Name Date From Date To Nature of Client’s Business Interim Title Nature of Assignment Length of Assignment No of employees | of which directly managed Value of budget/portfolio managed
(4) Client Organisation Name Date From Date To Nature of Client’s Business Interim Title Nature of Assignment Length of Assignment No of employees | of which directly managed Value of budget/portfolio managed
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AF.MGM.1004 SECTION 6 – DECLARATIONS AND CONSENTS References herein to the Institute mean the Institute of Interim Management.
Application Form I declare that the statements made in this Application Form and in any documents supplied by me to support my application are, to the best of my knowledge and belief, factually correct and true.
I understand that, should any such statements made be found to be false or misleading, my membership will be subject to review and may be rescinded following the convening of the Institute’s Disciplinary Committee. I also understand that should my membership be rescinded, no refund of the unexpired portion of my subscription to the Institute will be made.
Consent to Membership I consent to become a member of the Institute and agree that, in the event of a winding up of the Institute and there being insufficient funds to meet all outstanding liabilities, I guarantee to contribute up to a maximum of £1 to help satisfy said liabilities.
Code of Conduct and Continuing Professional Development I agree that, whilst a member of the Institute, I will abide by the Institute’s Code of Conduct and will act at all times in a manner becoming to the Institute, to the profession of interim management and to fellow interim managers.
I further declare I am committed to self-development. As such, I intend to continuously maintain and develop my own professional skills as an interim manager, and as a functional specialist, and to aid others in their so doing.
Data Protection Act 1998 and Electronic Communications Act 2000 For the purposes of the Data Protection Act 1998, I consent to the Institute and its wholly owned subsidiary, IOIM Limited, holding and processing my personal data, which in particular include my e-mail address, for their legitimate purposes, as described in the Explanatory Notes available with this Application Form. In giving this consent, I understand that, except as mentioned in the next paragraph, my data will not be disclosed to any third party except with my express permission, or as required by law or other legal obligation. As indicated in the Explanatory Notes, in order to facilitate communication and opportunities among the membership, data of a non-sensitive nature from this Application Form is made available through the Institute website to other Institute members only. I confirm that other Institute members may have access to this data, together with my e-mail address.
In addition, I consent to the Institute using electronic communications to communicate with me with regard to formal matters, as envisaged by the Electronic Communications Act 2000.
Signed: Dated:
………………………………………………… …………………………………………………..
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AF.MGM.1004 SUPPLEMENTARY INFORMATION Industry/Sector experience (in the list below, please indicate (X) a maximum of five industries/sectors that best reflect your experience.) Aerospace Leisure & Entertainment Agriculture/Forestry Manufacturing Arts & Theatre Mechanical Engineering Automotive Not for profit/Charities Biotechnology Petro-Chemical Building & Construction Pharmaceuticals Chemicals Ports & Warehousing Civil Engineering Printing, Packaging, Paper Clothing/ Textiles/Fashion Professional Services Cosmetics Public Sector Defence Publishing Distribution/Logistics Shipping Education Telecommunications Electrical Engineering Tourism/Travel Electronics Transport Financial Services – Banking TV & Radio Financial Services - Insurance Utilities & Energy FMCG Venture Capital/Private Equity Food, Drink, Tobacco World Development Health Care/NHS Other (please specify) Hotels & Catering International Banking International Insurance International Trade Iron, Steel, Metal IT, IS, Computing
Functional Specialisms (in the list below, please indicate (X) a maximum of five functional specialisms that best describe your area(s) of expertise.) Administration Operations & Quality Management Business Development Project Management Business Disaster Recovery Purchasing & Procurement Business Planning Research & Development Business Process Outsourcing Sales Change Management Supply Chain Management Commercial & General Management Training Communications & PR Other (please specify) Company Secretarial Compliance Corporate Finance Customer Service Facilities Management Fund-raising Human Resources
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AF.MGM.1004 SUPPLEMENTARY INFORMATION (continued)
Interim Roles (in the list below, please indicate (X) a maximum of five interim roles that best describe your area(s) of operation.) Advisor / Mentor Manager – Corporate Planning / Bus. Dev. Chairman – Executive Manager – Finance / Accounting Chairman – Non-executive Manager – Compliance / Audit Company Secretary Manager – HR / Training Director – Non-executive Manager – PR / Communications / Media Director – Managing / Chief Executive Manager – Sales / Marketing Director – Corporate Planning / Bus. Dev. Manager – Supply Chain Director – Finance / Chief Financial Officer Manager – Eng / Tech Director – Compliance / Audit Manager – Prod Dev / Research Director – HR / Training Manager – IT Director – PR / Communications / Media Manager – Program / Project / Change Mgmt Director – Sales / Marketing Manager – Other Disciplines Director – Supply Chain Specialist – M&A / Disposals / Restructuring / Bus. Dev. Director – Eng / Tech Specialist – Finance / HR / Admin / Compliance / Audit Director – Prod Dev / Research Specialist – Sales / Marketing / PR / Communications Director – IT Specialist – Manufacturing / Logistics Director – Program / Project / Change Mgmt Specialist – IT / Technical / Scientific / Prod Dev / Research Director – Other Disciplines Specialist – Other Disciplines General Manager Other
Do you hold Professional Indemnity Insurance? (Yes/No)
Do you hold Public Liability Insurance? (Yes/No)
Do you hold Employer’s Liability Insurance? (Yes/No)
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AF.MGM.1004