License Renewal

I,

Name*

First Last

hereby confirm that:

Professional Indemnity Insurance

I have current Professional Indemnity Insurance

due for renewal on*

Policy Number*

CPD

I have completed

Continuing Professional Development Hours*

Please enter the total number of hours of CPD activities you have completed

CPD Hours with IOBM*

Please enter the number of hours of CPD activities you have completed with IOBM

Supervision

Supervision Agreement

I have complied with the Terms of my IOBM Supervision Agreement and have completed

Hours of regular monthly Supervision*

Please enter the number of hours regular monthly supervision completed

My Named Supervisor is*

Conferences

Attended IOBM Conference

I attended the IOBM Conference on

Conference attended

Please enter the date of the last IOBM conference you attended

Planned IOBM Conference

I plan to attend the IOBM Conference on

Conference planned

Please enter the date of the last IOBM conference you plan to attend

OR

In process of completing arrangements

I am currently in the process of settling all my arrangements for Compliance with IOBM

Undertaking and Declaration

Consent*

I confirm that the above is true.

Signature*

Date*

Payment

Annual License Fee (£150 / €180)*

I have already paid
I will pay

Payment Method*

BACS Transfer UK
BACS Transfer Ireland
UK Standing Order 3 x £50 payments on 28th Feb / 30th April / 30th June
Ireland Standing Order 3 x €60 payments on 28th Feb / 30th April / 30th June

Payment Method*

Online with PayPal or Debit / Credit Card
BACS Transfer UK
BACS Transfer Ireland
UK Standing Order 3 x £50 payments on 28th Feb / 30th April / 30th June
Ireland Standing Order 3 x €60 payments on 28th Feb / 30th April / 30th June

Please put your name as reference for BACS Payment

Annual License Fee

Price:

Amount to pay now

You have opted to pay the £150 Annual License Fee now through PayPal or using your debit / credit card.

Upon clicking 'Submit' you will be taken to PayPal to process your payment. You do not need to register for an account if you wish to pay by debit or credit card. You will be returned to this site for confirmation once payment has completed.