IPENZ Engineers New Zealand

Affiliate Membership of IPENZ

1. APPLICANT DETAILS

1.1 Details previously held by IPENZ Database(please tick one)
Are you or have you previously been an IPENZ member, IPENZ administered technical group member or ERB registered?

Yes No Unsure

1.2 CONTACT DETAILS

Surname:	Initials:	Title:
Forename:	Preferred Forename:

Date of Birth:

Gender:
Male Female

Home Information
Home Address:

Post Code:
Home Telephone:	Home Facsimile:
Home Cell phone:	Home email:

Business Information
Employer:

Position:

Business Address: (P.O. Box or Private Bag)

Post Code:
Business Telephone:	Business Facsimile:
Business Cell phone:	Business email:

Alternative Contact Information (if applicable)
Address:

Post Code:
Alternative Telephone:	Alternative Facsimile:
Alternative Cell phone:	Alternative email:

1.3 BRIEF DESCRIPTION OF YOUR CURRENT ROLE

1.4 QUALIFICATIONS
List your academic qualifications - including Qualification, Discipline, Education Provider, Country and year.

1.5 CURRENT PROFESSIONAL MEMBERSHIP OR REGISTRATIONS
eg. IEAust, IEE, IStructE, IMechE, HKIE, ICE, ECSA etc

2.PRIVACY REQUIREMENTS & MEMBERSHIP DECLARATION

2.1 PRVACY ACT REQUIREMENTS

Marketing	Yes	No
I authorise IPENZ to give my name and contact details on a one-use-only basis to selective suppliers for marketing purposes.
Publishing Membership details:
I authorise IPENZ to publish my name and contact details in appropriate engineering journals, on the IPENZ website and provide my name and contact details to appropriate organisations seeking my type of expertise.
*IPENZ Mail*
I authorise IPENZ to mail me my IPENZ publications e.g "e.nz", eZine

Address you would prefer your mail to go to:
Home
Business
Alternative
Address you would prefer your email to go to:
Home
Business
Alternative

2.2 DECLARATION
Rule and Regulations/Code of Ethics
I agree that in the event of my election to membership of any class in IPENZ I will be governed by the Rules and Regulations of the Institution, including the Code of Ethics, as they are or as they may hereafter be altered, and that I will advance the objects of the Institution as far as shall be within my power.

I certify that the information, in this application form and in any supporting documentation, is correct.
I agree
I dont agree