Report Form for the Direct Award of CChem

Report Form for the
Direct Programme for Chartered Chemist
For holders of the Mastership in Chemical Analysis (MChemA)
1. Current Category of Membership
Current Category (please tick)
Member
Fellow
Membership number
Date of MChemA award
2. Personal Details
Family name
First name(s)
Home address
Postcode
Telephone number
Email
Job title
Employer’s address
Postcode
Telephone number
Brief job description
3. Mentor Details
4. Final Report
All sections must be completed
A. Summary of Evidence for CChem
Knowledge/Skills/Competence
Evidence
Mentor’s Comments & Signature
B1 Demonstrate Reliability, integrity
and respect for confidentiality on work
related and personal matters.
B.3 Demonstrate the ability to work as
part of a team.
C.3 Exert effective influence.
E. Demonstrate an interest in broader
developments in chemical science and
make a contribution to the profession
outside your usual job remit.
B. MChemA History
Within 12 months of the award of
your MChemA
No additional evidence required
More than 12 months since the
award of your MChemA
Appointment as a Public Analyst in the last two years. Please supply verification.
C. Review of performance and final recommendation
To be completed by the mentor
Do you recommend award of CChem? (Please tick)
Yes
No
Mentor’s signature
5. Payment
Payment by cheque
I enclose a cheque payable to ‘Royal Society of Chemistry’ for
£
Payment by card
Please charge my credit/debit card
Cardholder’s address (if different from Section 2)
(delete as appropriate)
Amount
£
Cardholder’s name
Card number
Valid from MM/YY
Cardholder’s signature
Expiry date MM/YY
Issue no.
Date
Notes
Please ensure you refer to the Guidance Notes for MChemA holders at
http://rsc.li/qp-register and the general guidance notes for CChem at
http://rsc.li/cchem.
If you have any questions relating to your application,
please contact:
Membership Department
Royal Society of Chemistry
Thomas Graham House
Science Park
Milton Road
Cambridge CB4 0WF
Tel: +44 (0) 1223 432141
Fax: +44 (0) 1223 432359
Email: [email protected]
Completing the Report form
Completed forms together with three copies of your
evidence should be sent to the Membership Operations Manager
at the above address.
Please complete the form in full, using typescript or by writing
clearly in black ink.
Forms which are poorly completed or lack the necessary
information will be returned.
In all cases the mentor is expected to have sufficient knowledge
of the candidate’s work.