Membership Form

    AGS MEMBERSHIP APPLICATION

    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.


    Personal Data

    Prefix (select appropriate title) :
    ProfDrMrMrsMs

    First and Middle Names :

    Family Name :

    Gender :
    MaleFemale

    Date of Birth :

    Email :

    Phone (home) (optional) :

    Phone (work) :

    Fax (optional) :

    Personal URL (optional) :

    Postal Address for Surface Mails (optional):


    Professional Data

    Affiliation/Institution/Company :

    Department :

    Address :

    Town/City :

    State/Province :

    Country :


    ACADEMIC RECORDS: Your academic background (degrees, where and when obtained, and a statement of your specialization).

    One record per Line

    Format -
    Degree University - Year of Graduation - Course
    (mention the major Subject) - Specialization


    Scientific Interest(s)

    Areas of Scientific Interest include :

    1. Solid Earth Science
    2. Atmospheric Science
    3. Ocean Science
    4. Astronomy and Planetary Science
    5. Solar and Terrestrial
    6. Hydrological Science


    Please indicate section(s) of interest :


    Referees: Give addresses, email and telephone of two referees who can be contacted

    1.
    2.


    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.

    YesNo


    Upload Scanned Signature :

    Passport Photograph :


    NOTE: By submitting this form, you agree to tender an application for membership of AGS.

    Today's Date :