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Company Name:

Permit No:
Cancellation/Change Requested by:
Position with Company: Chief Operating Operator Responsible Member
  Both Attorney
Permit to Practice granted for: All Engineering Geology Geophysics
Is cancellation /change requested for full permitted practice, or one of the professions:
  All Engineering Geology Geophysics
REASONS FOR CANCELLATION OR CHANGE (Please complete applicable section(s))
1. Company has ceased to operate (outline reason - retirement/death/closing down operations/merger)

2. Company purchased by/merged with another Permit Holder (if so, please state name & permit number of new owner);

3. If due to Retirement/Life Membership status, state if you are the sole practitioner (acting as both Chief Operating Officer and sole Responsible Member)

4. No APEGGA Member on staff to assume role of Responsible Member for the profession(s) being practiced. Please clarify:

5. Company still active. (Please provide detailed information regarding corporate activities):

6. Other (indicate reason(s) and clarify scope of corporate activities - i.e. name change to existing corporation and change of business activities):

7. Stamps and certificates enclosed Yes No If no, please state reasons:



Dated this ____________ day of ________________ 20 _______

Signature: ____________________________________________
*NOTE: APEGGA requires detailed information prior to cancelling or to change the status of a Permit to Practice. Simply stating that the company is"not practicing" is not sufficient.