Conversion To Member Application Form
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1S
E
G
, I
.
OCIETY OF
CONOMIC
EOLOGISTS
NC
Conversion to Member Application
7811 Shaffer Parkway • Littleton, CO 80127-3732 USA • Tel: +1.720.981.7882 • Fax: +1.720.981.7874 • E-mail:
S
I
(
)
ECTION
TO BE COMPLETED BY APPLICANT
Personal Information:
(Type or Print)
Ms / Mr / Dr ___________________________________________________
_________________________________
__________ Date of Birth ___________
Last Name
First Name
Middle Initial
Mo. Day Yr.
Company / Institution ____________________________________________________________________________________________________________________
Provide Mailing Address
Home or
Business _________________________________________________________________________________________
City ________________________________________ State/Province ________________________ Postal Code ________________ Country____________________
Phone _______________________________________ Cell ________________________________________ Fax _________________________________________
Email _____________________________________________________________ Alternate Email ______________________________________________________
Male
Female
Education:
(Type or Print)
UNIVERSITY AND LOCATION
YEARS
DEGREE
YEAR
Highest Degree: ________________________________________________ From ______ To_______
________________________________________ ______
Other Degree:
________________________________________________ From ______ To_______
________________________________________ ______
________________________________________________ From ______ To_______
________________________________________ ______
________________________________________________ From ______ To_______
________________________________________ ______
Professional Experience:
(List in order with most recent at the top)
YEARS (M/YR)
POSITION
EMPLOYER
From ______ PRESENT
_______________________________________________
_____________________________________________________________
From ______ To _______ _______________________________________________
_____________________________________________________________
From ______ To _______ _______________________________________________
_____________________________________________________________
From ______ To _______ _______________________________________________
_____________________________________________________________
PLEASE NOTE: If you are converting from Student or Recent Graduate to Member without a lapse in your
S
II
ECTION
membership, then you DO NOT have to complete Section II. Dr. Brian Hoal, SEG Executive Director, will sign as your
sponsor.
I sponsor the above-named individual for
MEMBERSHIP
To the best of my knowledge the information provided by the applicant is correct.
Sponsor’s Name (Type or Print) ____________________________________ Email Address_____________________________________
BRIAN G. HOAL
Signature _____________________________________________ Date ___________
FELLOW, Society of Economic Geolotists, Inc.
HEAD, Earth Science Dept. (For Student Sponsorships)
All new membership applications processed in the period SEPTEMBER 1 to DECEMBER 31
will have an effective date of the following JANUARY 1.
9/1
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