Application for Fellowship and 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 ____________________   GSL 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 (www.geolsoc.org.uk). Applicants for Chartership must be elected to Fellowship and pay relevant subscription fees along with application for Chartership (refer to GSL regulations for criteria for election as a Fellow).
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	

	

	

	

	

	

	

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)	

DECLARATIONS BY CANDIDATE	

DECLARATION BY APPLICANT FOR FELLOWSHIP	
  
I declare that I am willing to support the aims of the Geological Society of London and wish to apply for admission to Fellowship of the Society.

I declare that the statements made throughout this application are correct.

I agree that if elected to Fellowship, I will observe its Bye-laws and Regulations, including the Code of Conduct (available on GSL website)

I agree that if elected to Fellowship, I shall endeavour to promote the interests and welfare of the Society.

I further agree that I shall pay such dues as required of me on or before the specified dates and in the manner prescribed by Council.

I will pay directly to GSL the relevant application fees for Fellowship (see subscription form available from GSL) 

Signature  ________________________________________________________Date_______________________________

	
DECLARATION BY APPLICANT FOR CHARTERSHIP	

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 will pay directly to GSL fees for Chartered Geologist (see subscription form available from GSL)

I enclose the AIPG administrative 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

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.

	

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 Director				                                                Date	
	
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