APPLICATION TO WRITE THE PROFESSIONAL PRACTICE EXAMINATION

Please Print Clearly:

Name in Full		APEGGA Office Use Only
Mailing Address		Pseudonym Number
		Member Number
		Amount
Business Telephone:	Home Telephone:	Receipt Number
I wish to write the Professional Practice Examination in: Calgary Lethbridge Edmonton Medicine Hat Fort McMurray Red Deer Grande Prairie __________other, subject to approval		Engineer Geologist Geophysicist M.I.T. Prof. Member Appl. Mark
on: January 18, 1999 (Deadline Date - December 1, 1998) April 19, 1999 (Deadline Date - March 1, 1999) July 19, 1999 (Deadline Date - June 1, 1999) October 18, 1999 (Deadline Date - September 1, 1999)
Enclosed is my cheque for $50.00 (G.S.T. exempt) made payable to APEGGA or Visa Master Card #_______________ Expiry Date:____________ Additional $50.00 "USA Writing Fee" is required (Payable in Canadian Funds).
Date:	Signature:
Note: Applications will not be accepted after the deadline date. Candidates who request a deferral to the next exam session, cancel after the deadline, or fail to write or pass the exam may not have their fees refunded, nor will a credit be carried to the next exam session.

REG/OCTOBER 1998