Download - Society of Economic Geologists

APRIL 2006 • No 65 SEG NEWSLETTER 41SOCIETY OF ECONOMIC GEOLOGISTSMembership ApplicationSECTION I (TO BE COMPLETED BY APPLICANT)Personal Information: (TYPE OR PRINT)Membership in the Society is open to all geoscience graduates holding a bachelor’s degree. Student Membersmust be full-time students. Subscriptions to the journal, Economic Geology, and the quarterly SEG Newsletterare included in the membership. Applicants should submit this form with the appropriate sponsor signature to:Society of Economic Geologists, Inc., 7811 Shaffer Parkway, Littleton, Colorado 80127-3732, USAPhone: +1.720.981.7882; Fax +1.720.981.7874; E-mail: seg@segweb.orgMs / Mr / Dr ________________________________________________________________________________________________________ ______________________LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH_______________________________________________________________________________________________________________________________COMPANY / INSTITUTIONMAILING ADDRESS_______________________________________________________________________________________________________________________________CITY STATE / PROVINCE POSTAL CODE COUNTRY_______________________________________________________________________________________________________________________________PHONE FAX E-MAILEducation: UNIVERSITY AND LOCATION YEARS (FROM – TO) DEGREE YEARHIGHEST DEGREE: ________________________________________________ __________________________________________________OTHER DEGREES : ________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Professional Experience: (LIST IN ORDER FROM MOST RECENT AT THE TOP)FROM (Month/Year) — TO (Month/Year) POSITION EMPLOYER_________________PRESENT _________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________ __________________________________________________________________________ ______________________________________________________ ___________________________________________________________________________ ______________________________________________________ ______________________________________________SECTION II (TO BE COMPLETED BY THE SPONSOR WHO MUST BE A FELLOW OF THE SOCIETY)I sponsor the above-named individual for Membership Student MembershipTo the best of my knowledge the information provided by the applicant is correct._____________________________________________________________________________________________________________________________________________________________SPONSOR’S NAME (TYPE OR PRINT)E-M AIL ADDRESS OR TELEPHONE NUMBERFELLOW, SOCIETY OF ECONOMIC GEOLOGISTS________________________________________________________________________ HEAD, EARTH SCIENCE DEPARTMENTSIGNATURE DATE (FOR STUDENT SPON SORSHIPS)WHEN THE APPLICATION IS APPROVED, I AUTHORIZE THE SOCIETY OF ECONOMIC GEOLOGISTS TO CHARGE THE APPROPRIATEMEMBERSHIP DUES TO: __Visa __MasterCard __AmericanExpress __Discover US$_______________MEMBERSHIP_________________________________________________________________________________CARD NO. EXPIRATION DATEMEMBERSHIP CATEGORIES AND BENEFITS ARE DETAILED ON THE REVERSE SIDE -- PLEASE INDICATE YOUR SELECTIONSignature of Applicant_________________________________________________________________DATE_________________