Form Rpg-A1-97- Application For Registration Mississippi State Board Of Registered Professional Geologists

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RPG-A1-97
PART A
APPLICATION FOR REGISTRATION
MISSISSIPPI STATE BOARD OF REGISTERED PROFESSIONAL GEOLOGISTS
P. O. BOX 22742
JACKSON, MS 39225-2742
Fill in all blanks; these forms may be filled in on screen and then printed, otherwise all entries
must be typewritten. All information must be supplied on the form. If an item is not applicable to you,
complete the blank with "not applicable". If insufficient space is provided for any item, attach
supplemental sheets (8½” x 11”).
Your signature to this form and its notarization constitute an affidavit as to the truth of all
information you have submitted.
Your application should be accompanied by a check payable to the Mississippi State Board of
Registered Professional Geologists. This will cover the application processing costs and is non-
refundable.
I hereby apply for Registered Professional Geologist (RPG) on
,19
.
I hereby apply for Geologist-In-Training enrollment (GIT) on
,19
.
GENERAL INFORMATION
Full Name:
Home Address:
City/State/Zip:
Home Phone:
SSN:
Date of Birth:
Place of Birth:
Email (home):
Email (work):
Employer:
Employer Address:
City/State/Zip:
Business Phone:
FAX:
State of Legal Residence:
Have you ever been convicted of a felony or pleaded "no contest" to a criminal charge?
Yes
No
If yes, explain:
RPG-A2-97
Page 3 of 54 - October, 1999

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