Application For Registration
FOR ENGINEERS REGISTERED ELSEWHERE IN CANADA & USA.  
Please read the accompanying instructions carefully before you fill out the form.

 

I wish to apply for registration as a :
 Professional Member
Foreign Licensee


in the practice of

For Office Use Only

Member Number:  
Employer Number:
Comp. Entry          
Receipt Number    
Amount            		 _______________
_______________
_______________
_______________
_______________
Engineering 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 19
Date of Birth Month/Day/Year   Place of Birth

2.  POST SECONDARY EDUCATION

Institution
Location
Dates Attended
(Mo/Yr)
 Dates 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 includes dates, (month/year), technical responsibilities & accomplishments, management responsibilities, communication 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 National Professional Practice Examination for the __________________(province)   Association.   (...click here for Act, Regulations & By-laws Confirmation)

  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 State(s)  Include Years Registered
I previously applied for registration with APEGGA in   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 
                                                                         Other Province(s)/States(s)/Country(ies)
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 misrepresentaton 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 conditions 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 October 1999

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