APPLICATION FOR REGISTRATION

FOR GEOSCIENTISTS REGISTERED ELSEWHERE IN CANADA
Please read the accompanying instructions carefully before you fill out the form.

I wish to apply for registration as a :

Professional Member
Foreign Licensee

For Office Use Only

Member Number:  
Employer Number:
Comp. Entry:         
Receipt Number:  
Amount:        		 _________________
_________________
_________________
_________________
_________________

Geology
Geophysics

1. PERSONAL INFORMATION   Mr. Ms. Dr.

LEGAL NAME
Surname, Given Name in Full (NO Initials)

PREFERRED NAME
Surname, Common
Names and/or Initials
HOME ADDRESS
City
Province  Postal Code 
Telephone Fax
E-Mail
BUSINESS ADDRESS
City
Province Postal Code 
Telephone Fax
E-Mail
COMPANY NAME     

Preferred Address

Home    Business   Other (attached)    
Citizenship Canadian Citizen 
  Admitted to Canada for permanent residence in _______.Year
Date of Birth  Month/Day/Year
Place of Birth

2. POST SECONDARY EDUCATION

Institution

Location

Dates Attended (Mo/Yr)

Date of Graduation
(Mo/Yr)

Degree or Diploma
(Use correct abbrev. title)

Specialization
or
Discipline

1

From

To

2

From

To:

3

From

To

3. EXPERIENCE

Attach a resume. For each position include dates, (month/year), technical responsibilities & accomplishments, management responsibilities, communications skills required and an understanding of the societal implications of your work.

4. REFERENCES

Name

Relationship

Professional Status

Address

1

2

3


5. CHARACTER

Have you ever been found guilty of, or is there an outstanding judgement against you for:

a) unprofessional or unskilled practice by a professional regulatory organization or agency? Yes No

b) an offence under the Engineering, Geological and Geophysical Professions Act or Regulations or equivalent legislation in other jurisdictions? Yes No

c) any criminal offence? Yes No

d) negligence due to unskilled practice of the professions in any civil actions made against you? Yes No

6. KNOWLEDGE OF PROFESSIONAL LAW & ETHICS

I have passed the Professional Practice Examination for the___________________(province) Association. (Act, Regulations & By-laws Confirmation enclosed.

I will pass the National Professional Practice Examination to fulfill the registration requirements.

7. ENGLISH LANGUAGE COMPETENCY

English is my native language.

I have previously proven that I am competent in the use of the English language by virtue of

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

8. PROFESSIONAL STATUS

I am/was registered in ______________________________Province(s) or States(s) (Include Years Registered).

I previously applied for registration with APEGGA in and__________________Year and

was assessed examinations and/or experience which has not been completed.

was previously registered as a # from to .

am presently an MIT #___________________ .

I previously applied for registration with _____________________________________________Other Province(s)/State(s)/Country(ies) and

the application was refused/rejected
 my license was subsequently revoked.

* I declare that all the above statements are complete and correct to the best of my knowledge and belief. I agree to file additional information if the response to any question changes between now and the date of my registration. I understand that a false statement or misrepresentation may disqualify me for registration.

* I grant permission to APEGGA to obtain such additional information as it may deem appropriate from such additional sources as it may deem necessary to the progression of my application.

* I will conform to the requirements of the Engineering, Geological and Geophysical Professions Act of the province of Alberta, the Regulations including the Code of Ethics, and the By-Laws of the Association if granted membership in APEGGA.

* I declare that I do not have any alcohol or drug dependency or suffer from any medical condition that renders me incapable of fulfilling the requirements of a professional engineer, geologist or geophysicist.


Enclosed is my cheque for $___________________________ made payable to APEGGA or

Visa Master Card AMEX

#____________________________________________ Expiry Date: ________________________________

 

Date _____________________________ Signature_______________________________________________



REVISED JULY 2001