Form Rpg-A1-97- Application For Registration Mississippi State Board Of Registered Professional Geologists Page 8

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SECTION 2
THIS SECTION TO BE COMPLETED BY RESPONDENT WHO IS A GEOLOGIST AS
DEFINED BY THE ACT. SEE APPLICANT'S COMPLETE STATEMENT ON
PRECEDING PAGE- ALL ENTRIES ARE TO BE TYPEWRITTEN.
The applicant named above has filed an application for registration in the state of Mississippi as a
Professional Geologists. This process depends on the verification of the extent, diversity, and quality of
his/her practical training and experience as described on the reverse side. We therefore request your
assistance by filling out the form with consideration of the need for accurate data and for objective
appraisal of the applicant's ability or potential to practice geology. The applicant has provided in
PART D, Section 1, the job/timeframe which you are to verify.
Please return to the Board in the enclosed envelope.
Name of Respondent:
Current Business Address:
Position in Firm:
Are you a degreed geologist?
Business Phone:
Do you now hold a state professional certification, license or registration?:
Yes _____
No _____
List states and certificate, license, or registration number and date:
1. Describe applicant's character and personal reputation:
2. What is/was your business or professional relationship to the applicant:
3. Do you have knowledge of the applicant's participation in professional misconduct?
If yes, please explain:
4. Would you recommend this applicant for registration?
5. The portion of employment or experience we wish to verify is described by the applicant in the
previous section (Section 1). Please state your opinion regarding the accuracy of the description,
including extent and complexity of work.
Reference Signature:
Date: ________________________
RPG-A7-2-97
Page 10 of 54 - October, 1999

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