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KIM MEMBERSHIP UPGRADE APPLICATION FORM A. PERSONAL DETAILS Title: (Dr, Mr, Mrs, Ms) ____________ Surname: ______________________

Other Names: _____________________________________________

Membership No. ________________

Grade______________________

Years in Grade: ___________

Postal Address (include code): _______________________________________________________________________ Physical address: __________________________________________________________________________________ Mobile: ________________________ Email address: _____________________________________________________ Professional Membership other than KIM _______________________________________________ Grade______________________ _______________________________________________ Grade______________________ _______________________________________________ Grade______________________ _______________________________________________ Grade______________________ B. EMPLOYMENT DETAILS Position: ________________________________________________________

Date Appointed: _________________

Organization: _____________________________________________________________________________________ Address: ________________________________________________________

Code: _________________________

Business Phone: __________________________________________________

Fax: ___________________________

Email Address: ____________________________________________________________________________________

Total Number of Employees in company: _________

Total Managers/Supervisors reporting to you: _____________

Your Immediate Superior’s Position Title: _______________________________________________________________ 1


C. ANY NEW ACADEMIC OR TECHNICAL TRAINING SINCE LAST APPLICATION (ATTACH CERTIFIED COPIES) INSTITUTION /ORGANISATION

CERTIFICATION

From (dates)

To (dates)

D. LIST ANY CONTINUOUS PROFESSIONAL DEVELOPMENT COURSES/EXAMINATIONS ATTENDED/UNDERTAKEN SINCE YOU WERE ADMITTED TO KIM (ATTACH CERTIFIED COPIES) DURATION Course

Year

Organization/institution

CPD Hours

E. APPLICATION TO THE MEMBERSHIP COMMITTEE I hereby apply for the upgrade from my current membership grade of _______________________ to the membership grade of ___________________. I agree to accept the committee decision. Signature of Applicant: ___________________________________

Date: _________________________________

F. ACCEPTANCE As required under the admission requirements, I acknowledge that I will abide by the Code of Ethics and Professional Conduct and to complete at least 60 hours Continuing Professional Development (CPD) per annum. Signature of Applicant: ____________________________________

Date: ________________________________

G. ATTACHMENTS Atleast attach a one page profile detailing your recent achievements in the field management.

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/Membership_Upgrading_Form1  

http://www.kim.ac.ke/sites/files/Membership_Upgrading_Form1.pdf

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