8/3/2019 Regular Student Form_2011

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Student MeMberShip ApplicAtion ForM

I hereby apply for Student Membership of the European Association of Geoscientists & Engineers.

As a member, you will be registered as a member of the Oil and Gas Geoscience Division or

the Near Surface Geoscience Division .

Please tick the box or boxes of the division(s) that you wish to belong to:

Oil & Gas Geoscience Division Near Surface Geoscience Division

Your perSonAl detAilS Please type or write in block letters!

Dr  Drs  Ir  Miss  Mr  Mrs  Ms  PhD  Prof.  Prof. Dr

Surname  M/F

First name Initials 

Date of birth (not older than 29 years when applying) (dd/mm/yyyy)

univerSitY AddreSS

Name of University

Department

Address

Postal Code City

Country

E-mail

privAte AddreSS

Address

Postal Code  City

Country

Tel. Fax

E-mail

Preferred mailing address: Occasionally your details may be forwarded to other organisations forUniversity Private distribution of information that may be of interest to you.

If you would prefer that your details are not forwarded, tick this box

AdditionAl inForMAtion

iss (max. 2 answers) o sy afasEnvironment AAPGGeochemistry EEGS

Geology PESGBGeophysics SEGMining SPEPetroleum Engineering SPWLAPetrophysics Other (Speciy)

Reservoir Engineering

conditionS For the Student MeMberShip

• Notolderthan29years(whenapplying)• Fornewstudentmembersonly• Maximumtermisoneyear

8/3/2019 Regular Student Form_2011

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StAtuS

Student applicants must give information on the status and time-scale of their studies, countersigned by their professor.The duration of student membership is limited to five years.

Date expected to graduate (mm/yyyy)  Degree

Name of professor Signature of professor

College or University

Student Members are students who major in a geoscience or related engineering subject at a recognized university or institute.At the completion of his/her study a student member may convert his/her student membership to regular membership.

MeMberShip

Themembershipfeeis€25andincludesFirstBreak,Earthdoc(EAGE’ssearchablegeosciencedatabase),LearningGeoscience(e-learning journal) plus your choice of of the following journals: Petroleum Geoscience, Geophysical Prospecting, Near Surface Geophysicsor Basin Research (only online version).Should you wish to receive more journals,thereisanadditionalfeeof€25perjournal.Shouldyouwishtoreceivetheprintedversion as well as the online version of the selected journal, there is an additional fee of € 30. Aa ds (in Euros)

Membership €25The membership fee includes: - First Break (monthly) +

  - Learning Geoscience (e-learning journal) -Earthdoc(EAGE’ssearchablegeosciencedatabase)

s f jas (tick one box only): - Geophysical Prospecting (6x per year)  - Petroleum Geoscience (4x per year) - Near Surface Geophysics (6x per year)  - Basin Research (4x per year)  

Additional journals: - Geophysical Prospecting   €25- Geophysical Prospecting 1 € 30- Near Surface Geophysics   €25- Near Surface Geophysics 1 € 30- Petroleum Geoscience   €25- Petroleum Geoscience 1 € 30- Basin Research   €25

- Basin Research 1 € 30 

1 Only in combination with the online version o the journal 

MethodS oF pAYMent

Please debit my a: American Express Visa MasterCard/Access

Credit card number (plus security code): (American Express 4 digits and Visa/MasterCard 3 digits)

  Expiry date:   /  security code

In the amount of Euros (€)

Name of credit card holder

Signature of credit card holder

Paid by ak as / ak’s a in the amount of Euros (€)

Made out to: EAGE, bak: ABN-AMRO Bank, The Netherlands, A m:51.15.27.306,

ibAn m: NL56ABNA0511527306,bic/Sw : ABNANL2A

Signature Date (dd/mm/yyyy)

MeMberShip iS on A cAlendAr YeAr bASiS. MeMberShip ApplicAtionS receivedAFter 1 october Will be MAde eFFective AS oF 1 JAnuArY oF the FolloWinG YeAr

www.ag.g

pas m m g

w a y y s a :

eAGe ha ofMembership DepartmentPOBox59

3990DBHouten

The NetherlandsFax:+31306343534

Date and sign the orm and make a copy or your fles.

o gsa as aaa (www.ag.g)