Return to: Address Address Line 2 City State ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Name of Applicant: Date Signature Sponsor 1 SIPES No. 1 Sponsor 2 SIPES No. 2 Sponsor 3 SIPES No. 3 DPA CPG No. SPEE Member Page 2 Full Name as you would like it to appear on your membership certificate First Business City State ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Residense City State ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Name of Spouse Email Profession Specialty Social Security Paid By Business Type ConsultingNonconsultingPetroliumExplorationDevelopmentAppraisalOperationsResearchManagementOther Other Additional Qualifications List other earth science disciplines of competence and areas worked: Place of Birth Date of Birth Citizenship Detailed Statement of College Work From (Year) 1 To (Year) 1 College or University 1 Major (Specific Earth Science) 1 Degrees Received 1 Give Date 1 From (Year) 2 To (Year) 2 College or University 2 Major (Specific Earth Science) 2 Degrees Received 2 Give Date 2 From (Year) 3 To (Year) 3 College or University 3 Major (Specific Earth Science) 3 Degrees Received 3 Give Date 3 From (Year) 4 To (Year) 4 College or University 4 Major (Specific Earth Science) 4 Degrees Received 4 Give Date 4 Section Buttons Record of Exp Start (Year) 1 End (Year) 1 Company 1 Description of Work and Title 1 Start (Year) 2 End (Year) 2 Company 2 Description of Work and Title 2 Start (Year) 3 End (Year) 3 Company 3 Description of Work and Title 4 Start (Year) 4 End (Year) 4 Company 4 Independent Since (Year) Professional and Scientific Affiliations Name other scientific societies to which you belong, stating grade of membership and offices held, and honors received from these societies. List any certification and number. If you are a licensed professional, give state(s) and license number(s). Publications State title of any published articles, books, etc. of which you are the author; even if unpublished, give title and synopsis of your college thesis. If your bibliography is long, you may list titles of your major works and list groups of general subjects of others. You do not need to list all publications. Attach a Photo Here Section Buttons Page 3 LOCAL MEMBERSHIP COMMITTEE COMMENTS Sponsor 1 Comments Sponsor 2 Comments Sponsor 3 Comments Application Received Date Photo Signatures Affidavit Recommendation Further Investigation Approval Rejection Chairman, Local Membership Committee LMC Signature Date Section Buttons NATIONAL MEMBERSHIP COMMITTEE COMMENTS Recommendation Further Investigation Approval Rejection Chairman, National Membership Committee NMC Signature Date President Vice President Treasurer Secretary Section Buttons Submit
