VERY IMPORTANT INSTRUCTION: Please type the information into this form directly and then upload your scanned signature as appropriate. You may leave the signature space blank if you can’t scan your signature at this time.
Prefix (select appropriate title) : ProfDrMrMrsMs
First and Middle Names :
Family Name :
Gender : MaleFemale
Date of Birth :
Phone (home) (optional) :
Phone (work) :
Fax (optional) :
Personal URL (optional) :
Postal Address for Surface Mails (optional):
ACADEMIC RECORDS: Your academic background (degrees, where and when obtained, and a statement of your specialization).
One record per Line
Degree University - Year of Graduation - Course
(mention the major Subject) - Specialization
Areas of Scientific Interest include :
Please indicate section(s) of interest :
Referees: Give addresses, email and telephone of two referees who can be contacted
DECLARATION: I wish to become a member of African Geophysical Society and declare that the information in this application is correct to the best of my knowledge.
Upload Scanned Signature :
Passport Photograph :
NOTE: By submitting this form, you agree to tender an application for membership of AGS.
Today's Date :