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IVA MEMBERSHIP APPLICATION FORM
Title/Name (please print): Date of Birth: Address (including postcode): Contact Telephone Number: Qualifications I assess: Qualifications I internally verify: Qualifications I externally verify: Please complete the following Unit achievement record: D32 Award date: D33 Award date: D34 Award date: D35 Award date: D36 Award date: GPA Award date: I enclose a copy of my Assessor/Verifier Certificate(s) signed and dated by a Witness who has seen the original(s) and who is willing to be contacted as part of IVA authentication procedures. [ ] Name, Address and Contact Telephone Number of Witness: I enclose a cheque for £28 made payable to IVA Limited. [ ] Or Please invoice me for £28. [ ] If invoicing name or address is different from your own, please provide details, quoting any order or purchase number to be used.
Applicant’s Signature: Date:
Please send completed applications to the address below:
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