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Application for Certified Professional Geologist with the American Institute of Professional Geologists under the reciprocity agreement with The Geological Society of London Fellowship number ________________________ AIPG CPG Member number _________________ Instructions to Applicant Before filling out this form, please read the By Laws and Code of Ethics of the American Institute of Professional Geologists (AIPG), which must be followed by all Certified Professional Geologists with the AIPG (www.aipg.org). After completion of this form please return it to The Fellowship Office of The Geological Society, Burlington House, Piccadilly, London W1J 0BG for confirmation that you are a Chartered Geologist in good standing with the Geological Society of London. The Geological Society of London will then forward the completed form to the AIPG. This application is in the form of an affidavit to simplify the presentation of data without the necessity of submitting a professional report and supporting professional documents. Title Last name Date of birth First name Place of birth Middle name Sex Nationality/Citizenship Home address Work address (including name of organization) Zip code/Post code Country Zip code/Post code Country Telephone no: Telephone no: Email address: Passport/National Identity Card Information (please include passport style photo): Type: Issuing Authority: Number: Date issued: Expiration Date: To which address should correspondence be sent? (please mark box) Home: Work: RECORD OF COLLEGE/UNIVERSITY EDUCATION From To College or University (include location) Major subject 1 Degree received and dates AFFILIATIONS: List the geological societies and organizations of which you are an active member. (Attach additional page, if necessary.) Name of Organization Class of Membership Year granted Offices held Honors received PREVIOUS WORK EXPERIENCE: In chronological order, list the employers name and address, dates and nature of duties. Please include all periods, whether or not in the geological profession (Attach additional page, if necessary.) From To Employer, name and address CURRENT EMPLOYMENT: Employer: Address: Title: Nature of duties: VERIFICATION BY EMPLOYER/SUPERVISOR: Name: Position: Signature: LIST OF ATTACHMENTS: Passport Style Photo (may be electronically attached) 2 Description of Duties DECLARATION BY CANDIDATE I, the undersigned, wish to apply for the title of Certified Professional Geologist with the American Institute of Professional Geologists (AIPG). I hereby authorize the Geological Society of London to provide, from its records, any information concerning my qualifications as may be requested AIPG in support of this application. I declare that the degree qualifications and experience as set out in this application are correct. I do hereby agree that, if I am elected a Certified Professional Geologist, I shall promote the interests and welfare of the AIPG and observe its Statutes and Code of Conduct so long as I shall continue to be a Certified Professional Geologist I further agree that I shall pay such dues as are required of me on or before the specified dates and in the manner described by the AIPG. I enclose my application fee of £30. The fee for the American Institute of Professional Geologists will be assessed directly to the applicant. Signature: Date: Send the completed form and accompanying documents to: Fellowship Office, The Geological Society of London, Burlington House, Piccadilly, London W1J 0BG DO NOT WRITE BELOW THIS LINE Full Name of Candidate: Certified that the applicant is a Chartered Geologist in good standing. Geological Society of London, Executive Secretary Date COMMENTS: 3 Please indicate up to three fields of expertise and mark them one to three with one as the most important: If your field(s) is not listed please write in the blank boxes: EXPERTISE Appraisals/evaluations RATE EXPERTISE RATE Marine geology Coal Metallic minerals Computer applications Mining geology Construction materials Natural gas Economic geology Paleontology Engineering geology Petrology/mineralogy Environmental geology Petroleum Exploration Phosphates Field geology Planetology Forensic geology Remote sensing General geology/Earth science Sedimentology Geochemistry Seismology Geologic modeling Soil science Geomorphology Stratigraphy Geophysics Structural geology Geostatistics Tectonics Geotechnical Uranium Geothermal Volcanology Hazardous waste Waste disposal Hydrogeology Water resources Industrial minerals Investment analysis Please describe the general area of geosciences for which you are claiming competence (maximum of 20 words). This is particularly important to show the relationship between the fields you have indicated above. 4