PART 2 : CONTACT NAMES (PLEASE SUPPLY WHERE APPLICABLE) Managing Director Title: Technical Job title: Sales Job title: Accounts (for invoices etc.) Jo

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1 INDUSTRIAL ASSOCIATE SUPPORTER APPLICATION FORM Play a key role in your industry Industrial Associate Supporters play a key role in raising the profile of the industry. By working with the CIPHE you will be acknowledged for your commitment to professionalism. To apply to become an Industrial Associate Supporter, please complete this fillable PDF form and it to: membership@ciphe.org.uk We re here for you! Our Membership Department will be pleased to help you with any questions you may have. Please call us on +44 (0) (Monday to Friday 9am to 5pm), fax +44 (0) , membership@ciphe.org.uk or visit our website: Visit our website using the QR Code Reader on your mobile or tablet: PART 1 : CONTACT DETAILS Name of company/organisation: Address: Website: Town: Postcode: Telephone number: Parent company (if any): Brands: For office use only: Membership No.: Category: Accepted: Paid: Batch No.: RP No.: RHP No.: Branch:

2 PART 2 : CONTACT NAMES (PLEASE SUPPLY WHERE APPLICABLE) Managing Director Title: Technical Job title: Sales Job title: Accounts (for invoices etc.) Job title: To whom should your copy of the P&HE journal be sent? PART 3 : GET INVOLVED Would you like to be involved in the CIPHE s: Continuing Professional Development (CPD) Working groups Presenting at Branch technical events Other (please specify): PART 4 : ANNUAL TURNOVER Please declare the annual turnover of your company/organisation. Less than 2million per annum More than 2million per annum PART 5 : DATA PROTECTION Please tick if you would like to receive information about our products and services from: CIPHE Head Office and Branches: Post Telephone SMS

3 PART 6 : COMPANY/ORGANISATION PRODUCTS AND SERVICES Nature of business (please tick as appropriate): Architect Consultancy Distributor Educational body Fuel company Local authority Manufacturer Merchant Professional body Service provider Water undertaking Other: Service providers (please tick which your company/organisation provides): CCTV surveys Consultancy services Design Drain cleaning Energy conservation Energy services Fabrication services Maintenance Training and recruitment Testing Products manufactured (to be completed by manufacturers only) Air conditioning Appliances for the disabled Bathroom equipment Boiler manufacturers Building products Burners Products manufactured (to be completed by manufacturers only) Consumables Controls Convector heaters Drainage above/below ground Ducting Electric heating Energy efficient products Fans Floor drains Flues Fuel supply Grease treatment systems Heat pumps Heated thermal store Hot water cylinders Hot water supply Immersion heaters Industrial lighting and equipment LPG gas equipment Macerators Measuring equipment Pipes, tubes and fittings Pumps/circulators Radiant heaters Radiators Rainwater systems Refrigeration Sanitaryware Service provider Showers Solders and fluxes Solid fuel appliances Software Stainless steel products Syphonic roof drainage Tanks and cisterns Taps/valves Thermostatic mixing valves Tools and equipment Underfloor heating Unvented hot water systems Valves and fittings Ventilation Ventilation heat recovery units Warm air Waste disposal units Waste treatment Water heaters Water saving Water treatment Wholesome water products Workwear and clothing Other (please specify): This category may be added / allocated by the CIPHE

4 PART 7 : DECLARATION Please read and sign the declaration below. On behalf of the company or organisation named overleaf, I, the undersigned apply to be enrolled as an Industrial Associate Supporter of The Chartered Institute of Plumbing and Heating Engineering. I certify that the information that I have provided on this application form is true to the best of my knowledge, and that, if elected and enrolled, the company or organisation will agree to adhere to the Code of Professional Standards and be governed by the Royal Charter and Bye-Laws of The Chartered Institute of Plumbing and Heating Engineering. Position: Signature: Date: PART 8 : PAYMENT OF FIRST YEAR S SUBSCRIPTION FEE Please note that CIPHE subscriptions run on a yearly basis. All payments are to be made in sterling. Please see the list of current fees included in this membership pack. Please pay your entrance and supporter fee via cheque or credit/debit card. Cheque I enclose my cheque for made payable to CIPHE. Credit card Please charge my MasterCard/Visa/Delta/Switch/Solo/Amex (delete as necessary) with Card Number: Expiry Date: / Issue Number (Switch/Solo): Security Code: Name on card: Signature: Date: DON T FORGET... Before you send this form back to the CIPHE please take the time to double check that you have: Filled out every section of the form Read and signed the Declaration Attached payment details and Direct Debit details for future subscriptions Our Membership Department will be pleased to help you with any questions you may have: +44 (0) (Monday to Friday 9am to 5pm) Fax: +44 (0) membership@ciphe.org.uk Website: Visit our website using the QR Code Reader on your mobile or tablet:

5 PART 9 : DIRECT DEBIT PAYMENT OF FUTURE SUBSCRIPTIONS Instruction to your Bank or Building Society to pay by Direct Debit Please use this original form, not a photocopy. Fill in the whole form in CAPITALS using a BLACK ball point pen and post to: CIPHE, Membership Department, 64 Station Lane, Hornchurch RM12 6NB. Service User Number: Name(s) of Account Holder(s): Bank/Building Society account number: Branch sort code: Name and full postal address of your Bank/Building Society To: The Manager. Name of your Bank/Building Society: Address: Postcode: Reference/CIPHE Membership No.: Instruction to your Bank or Building Society Please pay The Chartered Institute of Plumbing and Heating Engineering Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that the Instruction may remain with The Chartered Institute of Plumbing and Heating Engineering and, if so, details will be passed electronically to my Bank/Building Society. For The Chartered Institute of Plumbing and Heating Engineering OFFICIAL USE ONLY This is not part of the Instruction to your Bank or Building Society If signature(s) is not that of the CIPHE member, please provide full postal address of signatory: Signature(s): Date: Name in Capitals: Address: This guarantee should be detached and retained by the Payer Direct Debit Guarantee The Guarantee is offered by all Banks and Building Societies that accept instructions to pay Direct Debits If there are any changes to the amount, date or frequency of your Direct Debit The Chartered Institute of Plumbing and Heating Engineering will notify you (normally 10 working days) in advance of your account being debited or as otherwise agreed. If you request The Chartered Institute of Plumbing and Heating Engineering to collect a payment, confirmation of the amount and date will be given to you at the time of the request If an error is made in the payment of your Direct Debit, by The Chartered Institute of Plumbing and Heating Engineering or your Bank or Building Society, you are entitled to a full and immediate refund of the amount paid from your Bank or Building Society If you receive a refund you are not entitled to, you must pay it back when the organisation asks you to You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify The Chartered Institute of Plumbing and Heating Engineering.

6 Become an Industrial Associate Supporter Industrial Associate Supporters play a key role in raising the profile of the industry. By working with the CIPHE they will be acknowledged for their commitment to professionalism. The CIPHE promotes a range of Continuing Professional Development courses to its members that are run by Industrial Associate Supporters to give technical presentations at CIPHE Branch evenings being held around the UK. Industrial Associate Supporters have the opportunity of working with the CIPHE on various projects and events, including conferences. They are also invited to contribute to Technical Papers, Dataflow Sheets and articles for P&HE journal. Can you join? The Industrial Supporter category includes many of the leading companies in the plumbing and heating industry you can join them! Companies and organisations that support the CIPHE s work can make application for the category of Industrial Associate Supporter. Candidates may be manufacturers, merchants, consultants, local authorities, fuel suppliers, water undertakings, professional and industrial associations etc. Keep in touch Like us on Facebook: Follow us on Twitter: Design

7 SEND US YOUR FORM Before you send this form back to the CIPHE please take the time to double check that you have filled out every section of the form. Once it is complete, please use the buttons (below) to save, print or/and your form. Please to: SAVE PRINT Thank you! CIPHE, Membership Department, 64 Station Lane, Hornchurch RM12 6NB.