American Institute of Professional Geologists Student Membership ...

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Student Membership is FREE while enrolled in a geological science degree program. ... Preferred Mailing Address: □ Hom
American Institute of Professional Geologists Student Membership Application Student Membership is FREE while enrolled in a geological science degree program.

Last Name:

First Name:

MI:

Suffix:

…Mr. …Ms. …Mrs. …Dr.

School Name:

Preferred Mailing Address: … Home … School Anticipated Graduation Date______Birth Year: Street: City: School Ph:

State:

Zip:

Home Ph:

Country: Fax:

Email: ATTESTATION: I attest that I meet the requirements for AIPG Student Adjunct (currently enrolled in a geological science degree program) and agree to abide by AIPG Bylaws and Code of Ethics.

Applicant Signature:

Date:

Print Faculty Sponsor Name:

Date: Mbr #:

Faculty Sponsor’s Signature (Required): HEADQUARTERS USE ONLY

Amt::

Rcvd:

American Institute of Professional Geologists Student Membership Application If applying between November 1 and June 30, the application fee is $20; if applying after June 30, the fee is $10.

Last Name:

First Name:

MI:

Suffix:

…Mr. …Ms. …Mrs. …Dr.

School Name: Preferred Mailing Address: … Home … School

Undergraduate … Graduate… Doctoral Candidate …

Birth Year:

Street: City: School Ph:

State:

Zip:

Home Ph:

Country: Fax:

Email: ATTESTATION: I attest that I meet the requirements for AIPG Student Adjunct (currently enrolled in a geological science degree program) and agree to abide by AIPG Bylaws and Code of Ethics.

Applicant Signature:

Date:

Print Faculty Sponsor Name:

Date: Mbr #:

Faculty Sponsor’s Signature (Required): HEADQUARTERS USE ONLY

Amt::

Rcvd:

American Institute of Professional Geologists Student Membership Application If applying between November 1 and June 30, the application fee is $20; if applying after June 30, the fee is $10.

Last Name:

First Name:

MI:

Suffix:

…Mr. …Ms. …Mrs. …Dr.

School Name: Preferred Mailing Address: … Home … School

Undergraduate … Graduate… Doctoral Candidate …

Birth Year:

Street: City: School Ph:

State:

Zip:

Home Ph:

Country: Fax:

Email: ATTESTATION: I attest that I meet the requirements for AIPG Student Adjunct (currently enrolled in a geological science degree program) and agree to abide by AIPG Bylaws and Code of Ethics.

Applicant Signature:

Date:

Print Faculty Sponsor Name: Faculty Sponsor’s Signature (Required): HEADQUARTERS USE ONLY

Amt::

Rcvd:

Date: Mbr #:

Place Stamp Here

American Institute of Professional Geologists 12000 Washington Street, Suite 285 Thornton, CO 80241 USA

Place Stamp Here

American Institute of Professional Geologists 12000 Washington Street, Suite 285 Thornton, CO 80241 USA

Place Stamp Here

American Institute of Professional Geologists 12000 Washington Street, Suite 285 Thornton, CO 80241 USA