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Your name has been given by  _______________________________________________
1.  How long have you known the applicant? Years
2.  In what capacity? 

Employer Supervisor Mentor Colleague Friend Client
3.  What position(s) has the applicant held?  Most recent first.   Repeat as necessary for each position on this form or attach additional sheets.
Dates Employed (month-year)
Position Title
Company and Location
Duration of Work Performed at each Level (see Note 1 below)
A B C D months
Nature of Responsibilities (see Note 2 below)
Note   1:     



A - Non technical training or orientation
B - Formal technical training
C - At a technician, technologist or technical support level
D - At a level where the application of engineering, geological or geophysical      principles was evident
           2: We are looking for not only the general responsibilities that can be found in a job description but, also the specific assignments, values, successes, degrees of independence and initiative needed as well as evidence of an increasing level of responsibility.
4.  Character  
Does the applicant exhibit the required character for professional registration?  
Yes No
Does the applicant understand and properly apply the principles of the Code of Ethics?      
Yes No
5. Application of Theory 
Has the applicant demonstrated the knowledge of and ability to apply principles of engineering geology or geophysics?

I don't know
Yes No
Does the applicant recognize and work with his/her own limitations?       
Yes No
6.  Practical Experience   Has the applicant had sufficient experience to practice the profession (engineering, geology or geophysics) with sound judgment and the application of sound principles?
I don't know
Yes No
7.  Communication
Has the applicant demonstrated an acceptable working knowledge of English?
Yes No
Has the applicant made written and oral presentations inside and outside his/her organization?
Yes No
8.  Management   To what degree has the applicant been responsible for people, project or technology management and been exposed to the organization's overall business environment?
Yes No
9.  Societal Implications  Has the applicant become aware of the societal implications of his/her work?
Yes No
I recommend that registration as a professional member in APEGGA be:
Approved   Deferred Withheld
If registration is deferred or withheld, how much more experience is needed?     months
Name:   (Please print)






I am a registered Professional  Engineer,   Geologist, Geophysicist

in the Province, State or  Country of:___________________________



Revised: October 1999