Report Form for the Direct Programme for Chartered Chemist For holders of the Mastership in Chemical Analysis (MChemA) 1. Current Category of Membership Current Category (please tick) Member Fellow Membership number Date of MChemA award 2. Personal Details Family name First name(s) Home address Postcode Telephone number Email Job title Employer’s address Postcode Telephone number Brief job description 3. Mentor Details 4. Final Report All sections must be completed A. Summary of Evidence for CChem Knowledge/Skills/Competence Evidence Mentor’s Comments & Signature B1 Demonstrate Reliability, integrity and respect for confidentiality on work related and personal matters. B.3 Demonstrate the ability to work as part of a team. C.3 Exert effective influence. E. Demonstrate an interest in broader developments in chemical science and make a contribution to the profession outside your usual job remit. B. MChemA History Within 12 months of the award of your MChemA No additional evidence required More than 12 months since the award of your MChemA Appointment as a Public Analyst in the last two years. Please supply verification. C. Review of performance and final recommendation To be completed by the mentor Do you recommend award of CChem? (Please tick) Yes No Mentor’s signature 5. Payment Payment by cheque I enclose a cheque payable to ‘Royal Society of Chemistry’ for £ Payment by card Please charge my credit/debit card Cardholder’s address (if different from Section 2) (delete as appropriate) Amount £ Cardholder’s name Card number Valid from MM/YY Cardholder’s signature Expiry date MM/YY Issue no. Date Notes Please ensure you refer to the Guidance Notes for MChemA holders at http://rsc.li/qp-register and the general guidance notes for CChem at http://rsc.li/cchem. If you have any questions relating to your application, please contact: Membership Department Royal Society of Chemistry Thomas Graham House Science Park Milton Road Cambridge CB4 0WF Tel: +44 (0) 1223 432141 Fax: +44 (0) 1223 432359 Email: cchem@rsc.org Completing the Report form Completed forms together with three copies of your evidence should be sent to the Membership Operations Manager at the above address. Please complete the form in full, using typescript or by writing clearly in black ink. Forms which are poorly completed or lack the necessary information will be returned. In all cases the mentor is expected to have sufficient knowledge of the candidate’s work.