Alaska Geological Society Membership Form

Please fill out the form below and mail completed form with a check to:

Membership Alaska Geological Society
P.O. Box 101288
Anchorage, AK 99510-1288

Name:__________________________________________________________________

Mailing Address: __________________________________________________________

_______________________________________________________________________

E-Mail Address:___________________________________________________________

Employer:__________________________________Position:________________________

Phone (h):________________________ Phone (w): _________________________

Education:

University / Year / Degree  /  Major

_____________________________/ _____/ _____/ _______________________

_____________________________ /_____/ _____/ _______________________

_____________________________ _____ _____ _______________________

Other Memberships:

(   )AAPG (class   ) (    ) Pacific Section AAPG (   )GSA (class    ) (   )AIPG (   )SEPM

Others:________________________________

Certifications:________________________________________________________

Membership Class:

(   ) Regular $15/yr (  ) Associate $15/yr (    ) Student $5/yr (    ) New Member (   ) Renewal

Signature ____________________________ Date ______________________