Application to

NA L PR OF ES SIO N AS
SOC I
OF PET RO ION AT

THE AMERICAN ASSOCIATION OF PETROLEUM GEOLOGISTS, INC. (hereinafter AAPG) DIVISION OF PROFESSIONAL AFFAIRS (hereinafter DPA)
AMERIC AN AS S
OF PETR ION OL IAT EU OC

S IR FA M GEOLOGI AF LEU

ICA ER

1917

P.O. Box 979 Tulsa, Oklahoma 74101-0979

DIVISION

ER

GY

M IN E R A L S DI

I VIS

Name _______________________________________________________________________________ Date _____________________________

Name of Applicant in Full

AAPG Member # ___________________________

This application includes a Declaration by the Applicant that is intended to establish an agreement with DPA members. It precludes the necessity of submitting transcripts of college credits, statements from employers, etc. All information requested on the form must be supplied; if an item is not applicable to you, complete the blank with no or none. If insufficient space is provided for any item, attach additional sheets containing the supplemental data.

Training Graduation from an institution of collegiate standing approved by the Division of Professional Affairs (DPA) Executive Committee, with major study in geology, with a minimum of thirty semester (45 quarter) hours in geology or their equivalent in geological instruction. Experience A minimum of eight years of full-time experience working as a Coal Geologist, which work is directly related to exploration for and/or development of coal deposits, during which period the applicant has demonstrated professional competence under responsible supervision or while self-employed. One year of experience credit may be given for the award of a masters degree or three years of experience credit may be given for the award of a doctors degree. (Experience in coal geology must be primarily applied. Such experience must be broad enough to include application of various disciplines of coal geology. Experience in specialty disciplines, e.g. log analysis, paleontology, sedimentology, geophysics, coal engineering, geologi-

1. Personal data Place of Birth _____________________________________________ Date of Birth ___________________ Citizenship __________________ Mailing Address _____________________________________________________________________________________________________
Street Address or Box No. City State/Province Zip/Postal

Employer _______________________________________________Position or Title_______________________________________________ Mailing Address _____________________________________________________________________________________________________

Street Address or Box No. City State/Province Zip/Postal

Daytime Phone __________________________________ E-mail: _____________________________________________________________

S ST

AM

M
G OGISTS OL GE

Certification as Coal Geologist (CCG)

INSTRUCTIONS TO APPLICANT Before filling out the form, you should read the Code of Ethics in the Constitution of AAPG because your signature affixed to this form warrants your knowledge and acceptance of the conditions and duties imposed by the Code of Ethics on the members of the Association, including a certified member, and constitutes a binding declaration as to the veracity of all statements submitted herein.

QUALIFICATIONS cal loging, coalbed methane, organic petrology, etc., shall not singularly fulfill the experience requirement.) Personal Integrity, Responsibility, and Professional Ability A sustained record of adherence to professional geologist and ethical standards of the Code of Ethics of AAPG attested to by at least three Sponsors who must be Coal certified members of the Association having present knowledge of the applicants professional qualifications and ethics. In the extenuating circumstance that such Sponsors are not available to the applicant, the applicant may be sponsored by noncertified AAPG active members having training and experience equivalent to the requirements for Coal Certification. Endorsement shall be furnished in writing. An evaluation will be conducted by AAPG into the applicants personal integrity, responsibility, and professional ability and these Sponsors will be contacted by AAPG in its evaluation pursuant to this application for Certification. (SPONSORS SHALL NOT BE EMPLOYEES OR SUBORDINATES OF THE APPLICANT.)

(Fill in all blanks using typewriter or print plainly in ink)

2. Record of Experience: Account for your activities, in chronological order, for the past twenty years or since graduation from high school. Describe in sufficient detail the type of geologic work done to allow evaluation with emphasis on those duties involving original judgement. If more space is needed, attach additional sheets. A resum is sufficient, if it outlines geologic experience and contains the information

requested above.
Please Print Legible Dates From*/To* Employer Name and Address Nature of Work and Title

*Give Month and Year 3. Scientific and Professional Society Affiliation. This information may also be supplied in a resum. Class of Membership and Date Elected Offices Held (with dates) Honors Received

Name of Society

4. Professional Qualifications: Give a concise statement of the particular experience and responsibilities, exclusive of academic training, which you feel especially qualify you for Certification, including the number of years so occupied. Other pertinent information which you feel should be brought to the attention of the Executive Committee may be included here. If more space is needed, attach additional sheets. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

5. Sponsors: The applicant is required to submit the names of three Sponsors who will attest to the applicants professional and ethical qualifications to become a Certified Coal Geologist. Where available, Sponsors must, themselves, be AAPG Certified Coal Geologists. Each Sponsor is required to complete a questionnaire detailing his/her qualifications for judging the applicant, and provide to the AAPG, in unequivocal terms, his/her opinion as to the applicants experience record, professional qualifications, ethics, and demonstrated ability in practicing and doing responsible work in coal geology. Sponsors should not accept this responsibility unless they are both willing and able to provide this information. If for any reason a Sponsor does not feel that the applicant should be accepted for Certification, that Sponsor should consider it the Sponsors duty to state the reason why Certification should not be extended. The applicant must provide to each Sponsor a duplicate copy of this completed application as submitted to AAPG. Each Sponsor must attest to the validity of that portion of the application of which the Sponsor has knowledge or has confirmed to the Sponsors satisfaction by inquiry and evaluation. SPONSORS SHALL NOT BE EMPLOYEES OR SUBORDINATES OF THE APPLICANT. Name and Mailing Address (Please print or type) Occupation or Title/Company Affiliation/Phone #s or e-mails

1. _____________________________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________________________ 6. Listed below are various coal geological disciplines. Indicate your skill level in each one by circling the number that is appropriate. This information is part of an important scientific resource base for the AAPG. 4 = Expert, highly experienced 3 = Substantial skill 2 = Moderate skill 1 = Limited skill 0 = No experience 1. 2. 3. 4. 5. 6. 7. 8. 9. Surface mapping and interpretation Subsurface mapping and interpretation Coal quality and geochemistry Geophysical interpretation Well log interpretation Coal and sedimentary petrology Paleontology Remote sensing and photogeology Reserve/resource analysis 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0

10. Mine site and water remediation

ARTICLE IV. CODE OF ETHICS

SECTION 1. General Principles

(a) Geology is a profession, and the privilege of professional practice requires professional morality and professional responsibility. (b) Honesty, integrity, loyalty, fairness, impartiality, candor, fidelity to trust, and inviolability of confidence are incumbent upon every member as professional obligations. (c) Each member shall be guided by high standards of business ethics, personal honor, and professional conduct. The word member as used throughout this code includes all classes of membership.
SECTION 2. Relation of Members to the Public

(a) Members shall not make false, misleading, or unwarranted statements, representations or claims in regard to professional matters, nor shall they engage in false or deceptive advertising (b) Members shall not permit the publication or use of their reports or maps for any unsound or illegitimate undertakings. (c) Members shall not give professional opinions, make reports or give legal testimony without being as thoroughly informed as reasonably required.
SECTION 3. Relation of Members to Employers and Clients

(a) Members shall disclose to prospective employers or clients the existence of any pertinent competitive or conflicting interests. (b) Members shall not use or divulge any employers or clients confidential information without their permission and shall avoid conflicts of interest that may arise from information gained during geological investigations.
SECTION 4. Relation of Members to One Another

(a) Members shall not falsely or maliciously attempt to injure the reputation or business of others. (b) Members shall freely recognize the work done by others, avoid plagiarism, and avoid the acceptance of credit due others. (c) Members shall endeavor to cooperate with others in the profession and shall encourage the ethical dissemination of geological knowledge.
SECTION 5. Duty to the Association

(a) Members of the Association shall aid in preventing the election to membership of those who are unqualified or do not meet the standards set forth in this Code of Ethics. (b) By applying for or continuing membership in the Association each member agrees to uphold the ethical standards set forth in this Code of Ethics. (c) Members shall not use AAPG membership to imply endorsement, recommendation, or approval by the Association of specific projects or proposals.
SECTION 6. Discipline for Violations of Standards

Members violating any standard prescribed in this Article shall be subject to discipline as provided by the Bylaws.

7. General Conditions: Any untrue or incorrect statement made by me in this application, or my failure to abide by the Code of Ethics and all other provisions of the Constitution and Bylaws of AAPG and the Bylaws of DPA, shall be sufficient grounds for revocation of my Certification. I understand and agree that Certification by AAPG shall be granted or refused according to the AAPG Certification procedures. I understand and agree that an evaluation will be made into my background in conjunction with this application for Certification and I authorize and request every person, firm, company, corporation, governmental agency, court, association, or institution having any information concerning me, whether or not such organization is associated with AAPG, to respond to AAPG, its agents or representatives and to inform AAPG fully as to any information requested and which any such person or entity may have. The actions and statements of AAPG, its agents and representatives, in any evaluation made as a result of the submission by me of this application for Certification and all responses by persons, firms, companies, corporations, and others responding to any inquiry of AAPG made in the investigation shall be privileged and not subject to any claim by me of libel or slander so long as such actions, statements, or responses are made in good faith and without gross negligence, recklessness or malice. I understand and agree that AAPG may from time to time impose requirements which must be met for those already Certified as Coal Geologists in order to retain such Certification and I will abide by and comply with all changes and requirements to maintain Certification which may be adopted from time to time by AAPG. I understand that in the event that I do not comply with such requirements my Certification as a Coal Geologist, should it be granted, will be subject to revocation and may be revoked, and I acquiesce in such changes and procedures and any enforcement thereof. 8. Declaration: DECLARATION BY THE APPLICANT (Please use this declaration or another process that is customary in your country for verifying the information listed below.) I, the undersigned, wish to apply for certification in the Division of Professional Affairs. In affixing my signature to this application I represent and warrant that: a) I have read this application as completed and all statements made herein and on any appended sheets are true and correct. b) I have read the Code of Ethics in the Constitution of the American Association of Petroleum Geologists, the provision in the AAPG Bylaws concerning Certification and Bylaws of the Division of Professional Affairs of AAPG and I subscribe to and will abide by the Code of Ethics of AAPG and all other provisions of the Constitution and Bylaws of AAPG and the Bylaws of the DPA. c) Have you ever been convicted of a felony? J Yes J No I declare that, if I am approved, I shall promote the interests and welfare of the Division of Professional Affairs through their Bylaws and AAPG Code of Ethics. I further agree that I shall pay such dues as are required of me on or before the specified dates and in the manner prescribed by AAPG and DPA as now in effect or hereafter amended. Accordingly, my fee(s) is included with this application.

Date _________________________________________________

Signature ____________________________________________________ (As Usually Written) Name _______________________________________________________ (Typed or Printed)

FOR OFFICE USE Application Received: __________________________________ Certified Delegate/Member: _____________________________ J Accepted J Rejected Month/Year Published: ________________________________________ Certificate No.: ______________________________________________ Applicant notified: ____________________________________________ Stamp/Seal ordered: ___________________________________________ ___________________________________________________________ Date ___________________________________________________________ Date ___________________________________________________________ Date

Notification from Board

Approved: ___________________________________________ Chm. Certification Board ____________________________________________________ EMD President ____________________________________________________ DPA President Certified Coal Geologist - 8/10