EDMONTON MEMBERS INDUCTION REGISTRATION FORM
BY INVITATION ONLY
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Number of guests attending:
None
One
Two
More than two (a $40 charge will apply for each additional guest)
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Member Number:
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Title:
Mr.
Ms.
Mrs.
Dr.
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First Name:
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Last Name:
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Professional Designation:
P.Eng.
P.Geo.
P.Geol.
P.Geoph.
P.L.(Eng.)
P.L.(Geo.)
P.L.(Geol.)
P.L.(Geoph.)
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Email Address:
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Current name of company you are employed by:
DEGREE(S):
(eg. B.SC., Mechanical Engineering, University of Alberta, 2001)
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1st Degree:
2nd Degree:
(if applicable)
3rd Degree:
(if applicable)
4th Degree:
(if applicable)
QUALIFYING EXPERIENCE:
Please list each position you have had within the last 4 years.
(eg. position, company)
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1st Position:
2nd Position:
(if applicable)
3rd Position:
(if applicable)
4th Position:
(if applicable)
DATE SELECTION
From the drop down menu please choose your preferred date of attending the event. If the date you have chosen is full you will be notified requesting you to select another date.
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Select preferred date:
--- please select
February 27, 2013 (deadline: February 6, 2013)
June 11, 2013 (deadline: May 21, 2013)
September 12, 2013 (deadline: August 22, 2013)
PAYMENT
You selected to bring more than two guests. You will be charged $40 for each additional guest.
Number of total guests:
3
4
You selected to bring 3 guests, you will be charged $40.00.
You selected to bring 4 guests, you will be charged $80.00.
Name on Card
Credit Card Type
Visa
MasterCard
AMEX
Credit Card Number
Expiration Date (mm/yy)
*
Indicates Response Required