REGISTRATION > Application for Registration

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Application For Registration

Please read the accompanying instructions carefully before you fill out the form. This is not an online submittal form as it requires your signature. Please fax to (780) 426-1877 or mail: 1500 Scotia One, 10060 Jasper Avenue NW, Edmonton, AB T5J 4A2.

I wish to apply for
registration as a :

Professional Member
Member-In-Training
Foreign Licensee
Student

For Office Use Only

Member Number:

Employer Number:

Comp. Entry:

Receipt Number:

Amount:

__________________
__________________
__________________
__________________
__________________

and to be assessed in

Engineering

Geology

Geophysics

Agricultural
Chemical
Civil
Computer
Electrical

Engineering Physics
Environmental
Geological
Geomatics
Industrial

Mechanical
Metallurgical
Mining & Mineral Processing
Petroleum
Software Engineering

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 20 ___.
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

Please attach a current resume in reverse chronological order (present position first) to your application outlining the following:

        * Company names and locations
        * Employment dates
        * Names of Supervisors
        * Positions titles

For each position include technical responsibilities & accomplishments, management responsibilites, communication skills required and an understanding of the societal implications of your work

3a POST GRADUATE ACADEMIC STUDIES - EXPERIENCE CREDIT

I am requesting experience credit for my post graduate academic studies Yes No

(Please note post-graduate experience credit is available only if your post-graduate degree is from a CEAB or ABET accredited institution. Refer to page 15 of the document entitled "Experience Requirements for Licensure: A Guideline").

If yes, please attach the title page, table of contents, abstract page, recommendation and conclusion portion of your thesis/project report and a letter of recommendation from your thesis supervisor which includes a statement about the engineering/geology/geophysics experience and engineering/geology/geophysics contribution of the research in the thesis.

4. REFERENCES

These individuals must be familiar with the significant time elements of your experience (if applying for Professional Membership).

	Name	Relationship	Professional Status	Complete Address and/or E-Mail 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 National Professional Practice Examination for the __________________ (province) Association.
I will pass the National Professional Practice Examination to fulfill the registration requirements.

7. ENGLISH LANGUAGE COMPETENCY

	English is my native language.
	I have attached a hand written letter explaining why I am competent in the use of the English language.
	I have previously written the Test on English as a Foreign Language. Attach copy of TOEFL score sheet.
	I will be writing the TOEFL to fulfil the registration requirements.

8. PROFESSIONAL STATUS

	I am not registered anywhere and have never applied.
	I previously applied for registration with APEGGA in (year) and

		was assessed examinations and/or experience which has not been completed.
		was previously registered as #
		from to
		am presently an MIT #

	I previously applied for registration with and
	Other Province(s)/States(s)/Country(ies)

		the application is pending.
		the application was refused / rejected.
		was assessed examinations and / or experience which has not been completed.
		am / was registered in
	Other Province(s / States(s) / Country(ies) Include Years Registered
		my license was subsequently revoked.

9. COMMENTS

________________________________________________________________________

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 December 2001