SRI LANKA INSTITUTE OF CREDIT MANAGEMENT ASSOCIATE / FELLOW MEMBERSHIP APPLICATION FORM R E FE R E N C E Please complete this entire application and attach all supporting documentation. Incomplete applications or those missing necessary documentation will be returned to you for resubmission with requested materials. To help us process your application, please indicate the number of year s you have been working in credit, read the statements below and tick those that best describe your current situation and intentions. Length of time working in credit Years S L I C M M E M B E R S H I P I wish to apply for Associate Membership. Student Membership number I am an Associate Member and wish to apply to upgrade to Fellow. Membership number current grade I have previously been a Member and wish to rejoin. Membership number Note Associate (AICM) or Fellow (FICM) Membership grade will be awarded according to your credit experience and qualifications. Membership grade will be awarded according to your credit experience and qualification PERSONAL INFORMATION P L E A S E P R I N T I N B L O C K L E T T E R S T I T L E M R M I S S MS M R S O T H E R S U R N A M E O T H E R N A M E S D A T E O F B I R T H d d / m m / y y y y N I C N U M B E R P E R M A N E N T R E S I D E N C E A D D R E S S T O W N / D I S T R I C T T E L E P H O N E N O M O B I L E N O P E R S O N A L E M A I L Please attach a copy of your NIC / Passport / Driving License as proof of your identity
PAGE 2 OF 5 DETAILS OF EMPLOYMENT P O S I T I O N / T I T L E N A M E O F O R G A N I S A T I O N N A T U R E O F B U S I N E S S D A T E O F J O I N I N G N O O F Y E A R S O F E X P E R I E N C E R E P O R T I N G T O N O O F D I R E C T S U B O R D I N A T E S O F F I C I A L C O M P A N Y A D D R E S S T E L E P H O N E N U M B E R M O B I L E N U M B E R E M A I L A D D R E S S EDUCATIONAL QUALIFICATIONS T I T L E O F A W A R D A W A R D I N G B O D Y Y E A R O B T A I N E D PROFESSIONAL QUALIFICATIONS N A M E O F D E G R E E / A W A R D U N I V E R S I T Y / A W A R D I N G B O D I E S Y E A R C O M P L E T E D
PAGE 3 OF 5 PROFESSIONAL MEMBERSHIP P R O F E S S I O N A L B O D Y G R A D E Y E A R A D M I T T E D PREVIOUS EMPLOYMENT Disregarding your current job please provide details of your previous employment, starting with the most recent. F R O M TO (MONTH & YEAR) E M P L O Y I N G O R G A N I S A T I O N I M M E D I A T E R E P O R T I N G L I N E M A N A G E R (NAME & JOB TITLE) T I C K I F T H E J O B W A S M A N A G E M E N T L E V E L Please attach your resume and give reasons for any break in continuity of employment
PAGE 4 OF 5 BUSINESS REFEREES Two Name(s) of referees with their respective official company rubber stamp confirming the length and nature of your credit experience. They should normally be your current and former line managers. N A M E O F R E F E R E E C O M P A N Y N A M E / A D D R E S S T E L E P H O N E / E M A I L L E N G T H & N A T U R E O F Y O U R C R E D I T E X P E R I E N C E S I G N A T U R E / R U B B E R S T A M P N A M E O F R E F E R E E C O M P A N Y N A M E / A D D R E S S T E L E P H O N E / E M A I L L E N G T H & N A T U R E O F Y O U R C R E D I T E X P E R I E N C E S I G N A T U R E / R U B B E R S T A M P
PAGE 5 OF 5 MEMBERSHIP GRADES Detailed below is the SLICM membership structure grade, which shows the grades available to you now. ASSOCI AT E MEM BER Rs. 4250/ - For those who have passed the SLICM Diploma with a minimum of 2 Years credit employment experience FELLOW MEM BER Rs. 7500/ - For Associate (AICM) and professionals who meet the current Fellowship criteria at the discretion of the Council of Management PLEASE ATTACH THE FOLLOWING DOCUMENTS Please include the following supporting document with your application Proof of Identity Job Description / Profile Enclose copies of the SLICM Diploma / Advance Diploma Certificate Please provide details of your qualifications along with copies of certificates for validation purpose. Original or certified copies of academic transcripts, showing all subjects attempted and grades received, MUST be attached for this application to be processed. DECLARATION I understand that the Institute may need to request additional information in order to assess my application for membership, and reserves the right to refuse any membership application. I declare that all the particulars that I have provided are correct. I undertake to further the best interests of the Institute and abide by its Code of Professional Conduct. NA M E & SI G N AT UR E O F T H E A PP L I CA NT DAT E TH I S F O R M M U S T B E R E TU R N E D A L O N G W I TH TH E S U P P O R TIN G D O C U M E N T A T I O N TO THE REGISTRAR, Sri Lanka Institute of Credit Management, Alliance House, No 84, Ward Place, Colombo 07, Sri Lanka