Form 08-4126 - Application For Certification As A Professional Geologist - 2001
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1GEO
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Geologist Certifications
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
APPLICATION FOR CERTIFICATION AS A
PROFESSIONAL GEOLOGIST
INSTRUCTIONS: Certification fee $50; optional wall certificate suitable for framing an additional $20. Make check
or money order payable to the State of Alaska. Please type or print requested information. Please complete this
form in its entirety. In support of this application, submit verification that you are certified as a professional geologist
by the American Institute of Professional Geologists (AIPG). Verification must be a notarized, certified true copy
of your AIPG certificate or AIPG card, or an original, signed, and sealed attestation from AIPG.
Name
Last
First
Middle
Maiden/Other
U.S. Social Security Number
Birthdate
Sex
(Required by AS 08.01.060(b))
Mailing Address
City
State
ZIP Code
Residence Address
City
State
ZIP Code
Telephone – Business
Home
I certify that the information in this application and the supporting documents is true and correct to the best of my
knowledge. I understand that any false or misleading information may result in failure to obtain certification or
subsequent revocation of my certification as a professional geologist in Alaska.
Sign Here
Applicant’s Signature
SUBSCRIBED AND SWORN TO before me on
________________________________ (date).
Notary Public, State of
(NOTARY SEAL)
My commission expires:
FOR OFFICE USE ONLY
License No.
AIPG No.
Issue Date
08-4126 (Rev. 2/01)
CONTINUED ON REVERSE
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