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	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)	

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, Professional Qualifications Officer			Date	
	
COMMENTS:	

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	
Appraisals/evaluations		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.