Download Application for Certified Professional Geologist with the American

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
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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)
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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:
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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.
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