Application foraward of the Certified Professional Geologists (CPG)

with the American Institute of Professional Geologists

under the reciprocity agreement with

the European Federation of Geologists

EurGeol number ______AIPG CPG Member number ______

Instructions to Applicant

Before filling out this form, please read the Bylaws and Code of Ethicsof the American Institute of Professional Geologists, which must be followed by all members and CPG’s of the American Institute of Professional Geologists.

After completion of this form please return it to:EFG Office,European Federation of Geologists, Rue Jenner 13, 1000 Brussels, Belgiumfor confirmation that you are a European Geologist member in good standing with the EFG. The EFG will then forward the form to the American Institute of Professional Geologists.

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 / First name / Middle name
Date of birth / Place of birth / Sex / Nationality/Citizenship
Home address
Zip code/Post code
Country
Telephone no: / Work address (including name of organization)
Zip code/Post code
Country
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 / 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 / Description of Duties
CURRENT EMPLOYMENT:
Employer:
Address:
Title:
Nature of duties:
LIST OF ATTACHMENTS:
Passport Style Photo (may be electronically attached)

DECLARATION BY CANDIDATE

I, the undersigned, wish to apply for the title of Certified Professional Geologist (CPG).

I hereby authorize the European Federation of Geologiststo provide, from its records, any information concerning my qualifications as may be requested by the American Institute of Professional Geologists 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 aCPG, I shall promote the interests and welfare of the American Institute of Professional Geologistsand observe its Bylaws and Code of Ethics so long as I shall continue to be aCertified 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 American Institute of Professional Geologists.

Signature: / Date:

Send the completed form and accompanying documents to:

EFG OFFICE

European Federation of Geologists

Rue Jenner 13, 1000 Brussels, Belgium

DO NOT WRITE BELOW THIS LINE

Full Name of Candidate:
Certified that the applicant is a European Geologist with the European Federation of Geologists in good standing.
EFG Executive DirectorDate
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:

Speciality Fields of Practice / RATE / Speciality Fields of Practice / RATE
Appraisals/Evaluations / Management
Coal / Marine Geology
Cold Regions/Permafrost / Mathematical Geology
Computer Applications / Metallic Minerals
Construction Materials / Micropaleontology
Economic Geology / Mineralogy
Engineering Geology / Mining Geology
Environmental Geology / Natural Gas
Envir. Impact Assmt. / Operations/Development
Envir. Site Assmt. / Paleontology
Exploration / Palynology
Field Geology / Petrography/Petrology
Forensic Geology / Petroleum
General Geology/Earth Sci. / Phosphates
Geochemistry / Planetology
Geologic Modelling / Regional Geology
Geomorphology / Remote Sensing
Geophysics / Sedimentology
Geostatistics / Seismology
Geotechnical / Soil Science
Geothermal / Stratigraphy
Hazardous Waste / Structural Geology
Hydrogeology / Tectonics
Industrial Minerals / Uranium
Investment Analysis / Volcanology
Land Reclamation / Waste Disposal
Leasing / Water Resources

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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