Application for validation as a

Chartered Geologist of The Geological Society of London

under the reciprocity agreement with

the American Institute of Professional Geologists

AIPG CPG Member number ______Fellowship number______

Instructions to Applicant

Before filling out this form, please read the Code of Conduct of the Geological Society of London, which must be followed by all Fellows and Chartered Geologists of the Geological Society (

After completion of this form please return it to: American Institute of Professional Geologists, 12000 Washington St., Suite 285, Thornton, Colorado 80241 USA for confirmation that you are a Certified Professional Geologist member in good standing with the AIPG. The AIPG will then forward the form to the Geological Society of London.

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

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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:
VERIFICATION BY EMPLOYER/SUPERVISOR:
Name: / Position:
Signature:
LIST OF ATTACHMENTS:
Passport Style Photo (may be electronically attached)

DECLARATION BY CANDIDATE

I, the undersigned, wish to apply for the title of Chartered Geologist of the Geological Society of London.

I hereby authorize the American Institute of Professional Geologists to provide, from its records, any information concerning my qualifications as may be requested by the Geological Society of London 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 Chartered Geologist, I shall promote the interests and welfare of the Geological Society and observe its Statutes and Code of Conduct so long as I shall continue to be a Chartered 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 Council of the Society.

I enclose my application fee of $50 US. The fee for the Geological Society of London will be assessed directly to the applicant.

Signature: / Date:

Send the completed form and accompanying documents to:

American Institute of Professional Geologists

12000 Washington St., Suite 285

Thornton, Colorado 80241

USA

DO NOT WRITE BELOW THIS LINE

Full Name of Candidate:
Certified that the applicant is a Certified Professional Geologist with the American Institute of Professional Geologists in good standing.
AIPG 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:

If your field(s) is not listed please write in the blank boxes:

EXPERTISE / RATE / EXPERTISE / RATE
Computer Science/Data / Marine Geology
Contaminated Land / Mineral and Ore Deposits
Engineering Geology / Mining Geology
Environmental Sciences / Natural Hazards
Geochemistry / Oil and Gas
Geomaterials / Quarrying
Geomorphology / Quaternary Geology
Geophysics / Tectonics
Geotechnics / Waste Management
Hydrogeology

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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