Retired Membership Application Form

Retired Membership Application Form
This form must be completed if applying for Retired Membership.
Membership Number*
Name*

ForenameSurname
Home Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number*
Personal Email Address*
To retain my LIA designation(s) and comply with my CPD programme, while retaining the benefits of Qualified Membership, at a reduced rate.To surrender my LIA designation(s) and no longer participate in the CPD programme, while retaining the benefits of Associate Membership, at a reduced rate.
Payment by Direct Debit.Payment by Credit/Debit Card.
I acknowledge and confirm that:

1. I have permanently ceased full or part-time paid employment in any area.

2. I will re-certify my employment status annually where required and on request from LIA.

3. I have read, understood and agree to be legally bound by LIA’s Membership Terms and Conditions https://www.lia.ie/terms-and-conditions that may be amended from time to time.

4. I consent to LIA processing, holding and disclosing my personal data as per LIA’s Privacy Policy, which may change from time to time based on legal or regulatory requirement

5. I consent to the receipt of formal notices from LIA by electronic means (email and/or website).

6. I wish to be kept informed of other LIA products, services and related activities; and

7. I will notify LIA if I return to part-time or full-time employment and will take the necessary actions to adjust my membership status accordingly.
I confirm that the above statements are true and correct.
Signature*
Date*

MonthDayYear
Date

- Member Name *
  
  Forename(s)Surname
- LIA Membership Number *
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityCounty
  
  Postal Code
- Complete this section only if paying by Direct Debit.
  
  By signing this mandate form, you authorise LIA to send instructions to your bank to debit your account, and for your bank to debit your account in accordance with the instruction from LIA.
  
  You are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. Refund claims must be made within 8 weeks from the date your account was debited. Your rights are explained in a statement available from your bank.
- Account Number - IBAN
- Bank Identifier Code - BIC
- Account Holder Name(s)
  
  First NameLast Name
- First NameLast Name
- Account Holder Address
  
  Street Address
  
  Street Address Line 2
  
  CityCounty
  
  Postal Code
- Creditor’s name: LIA
  Creditor’s address: LIA House, 183 Kimmage Road West, Dublin 12, D12 XD2X
  
  Creditor identifier: I E 1 5 S D D 3 0 0 8 5 0
- Unique Mandate Reference (UMR)
  To be completed by LIA
- Type of Payment
- Date of Signing
  
  MonthDayYear
  Date
- Signature

Retired Membership

Annual Subscription

€50.00 Quantity

Total

€0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: