EmailMe Form - Domestic Membership Application

About You

Title *

Forename *

Middle Name

Surname *

Former/Maiden Name

House No. / Name *

Postcode *

Email *

Phone Number *

Mobile Phone Number

Date of Birth *

DD / MM / YYYY

Gender *

Nationality *

Upload a copy of your Work Permit if not of UK origin

Upload a digital Photo of yourself *

Upload a copy of either your Driving Licence, Passport or Birth Certificate *

Passport Number

CRB/DBS Check *

Please Note:
1. Both Pages of the Document are required
2. Scanned images or photographs need to be of the whole document and of clear unblurred quality
3. Energy assessors must have evidence they have been subjected to a Criminal/Basic Disclosure within the past 12 months.

Page 2
(If Seperate)

About your Employer / Company

Employers/Company Name *

Address Line 1 *

Address Line 2

Address Line 3

Post Town *

Postcode *

Website *

Insurance Details *

I would like Pay Per Click Insurance

I have my own Insurance Policy - (Please Upload a Copy)

Upload Insurance Certificate

Accreditation your applying for

Please select the strands you wish to apply for

Accreditation Strands *

Domestic EPC

Application Route (Qualification / APEL) *

Application Region

England & Wales

Northern Ireland

Scotland

Your Qualifications

Qualification *

Certificate Number *

Date Awarded / Issued *

DD / MM / YYYY

Training Centre *

Awarding Body *

Upload a Copy of the Certificate *

Qualification

Certificate Number

Date Awarded / Issued

DD / MM / YYYY

Training Centre

Awarding Body

Upload a Copy of the Certificate

Software you are qualified to use

Energy Performance Certificate Software

LifespanRdSAP

Details of Professional Conduct

Have you ever been convicted of a criminal offence in the UK or elsewhere? *

Have you had an application to another accreditation scheme or professional body refused at ant time? *

Have any allegations of Breach of Professional Duty, any complaints or any claims been notified in the last 5 years, or are any actions pending? *

Have you ever been refused Professional Indemnity insurance, or have any additional clauses and limits been imposed upon you? *

Have you ever been disqualified as a Director *

Have you ever had bankruptcy proceedings against you? *

Have you ever been suspended or has your membership revoked by another accreditation scheme? *

Are you currently a member of any other accreditation scheme *

If you have answered yes to any of the questions above, please provide details

Continuous Professional Development

Please provide details of all the CPD you have done in the last 2 years *

Upload a copy of your Lifelong Learning record

Declaration

Please read and tick the box

I understand and agree that information regarding the status of my membership with Sterling will be shared with DCLG, the Register Operator and other schemes who I am also registered with.

Yes

I have read and understood the Declaration *

Yes

Please enter todays date *

DD / MM / YYYY