HGS Membership Application Form (from HGS Web Site)

To the Executive Board: I hereby apply for __Active __Associate membership in the Houston Geological Society and pledge to abide by its constitution and Bylaws. Check here ___ if a full time student.

Name:
Home Address:
Home Phone:
Spouse's Name:
Job Title:
Company:
Company Address:
Work Phone:
Fax Number:
Preferred mailing address: ____ HOME, ____ WORK (Select one)
Email Address:

Professional Affiliations and Interests:
Active AAPG Member: (Yes/No)
Other Memberships:

Please check your professional interests:
__Environmental Geology
__International E&P 		__North American E&P (other than Gulf Coast)
__Gulf Coast E&P (onshore and offshore)

Education
School:

 Degree: Major: Year:



School:

 Degree: Major: Year:



School:

 Degree: Major: Year:

Earth Science Work Experience (description): .

.

Applicant's Signature: ____________________________ Date:_____________

Endorsement by HGS member (not required if active AAPG member):

HGS Member Name: __________________________________________

HGS Member Signature: _____________________________ Date:_____________

Membership Chairman: __________________ HGS Secretary:______________________
Print a copy of this form, fill in the blanks and attach a check (U.S., $20 for Active or Associate, $10 for Student) payable to HGS. Note: payment may also be made in the form of a credit card. For credit cards, indicate: a. type b. number and c. expiration date

Send the completed form and check to: HGS, 10575 Katy Freeway, Houston, Tx 77024
(form updated: Jan. 20, 2003)