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REFERENCE QUESTIONNAIRE


Your name has been given by _______________________________________________

1. How long have you known the applicant? Years

2. In what capacity? Employer Supervisor Mentor Colleague Friend Client

3. What position(s) has the applicant held? Most recent first. Repeat as necessary for each position on this form or attach additional sheets.
Dates Employed	(month-year)
Position Title
Company and Location
Supervisor

Duration of Work Performed at each Level (see Note 1 below) A B C D months
Nature of Responsibilities (see Note 2 below)

Note 1:

A - Non technical training or orientation
B - Formal technical training
C - At a technician, technologist or technical support level
D - At a level where the application of engineering, geological or geophysical principles was evident

We are looking for not only the general responsibilities that can be found in a job description but, also the specific assignments, values, successes, degrees of independence and initiative needed as well as evidence of an increasing level of responsibility.


4. Character Does the applicant exhibit the required character for professional registration?	Yes No

Does the applicant understand and properly apply the principles of the Code of Ethics?	Yes No



5. Application of Theory Has the applicant demonstrated the knowledge of and ability to apply principles of engineering geology or geophysics?	I don't know Yes No

Does the applicant recognize and work with his/her own limitations?	Yes No



6. Practical Experience Has the applicant had sufficient experience to practice the profession (engineering, geology or geophysics) with sound judgment and the application of sound principles?	I don't know Yes No



7. Communication Has the applicant demonstrated an acceptable working knowledge of English?	Yes No

Has the applicant made written and oral presentations inside and outside his/her organization?	Yes No


8. Management To what degree has the applicant been responsible for people, project or technology management and been exposed to the organization's overall business environment?	Yes No


9. Societal Implications Has the applicant become aware of the societal implications of his/her work?	Yes No

I recommend that registration as a professional member in APEGGA be:

Approved

Deferred

Withheld



If registration is deferred or withheld, how much more experience is needed? months

Name: (Please print) _________________________________	Signature: _________________________________
Position: ________________________________	Date: _________________________________

I am a registered Professional Engineer, Geologist, Geophysicist in the Province, State or Country of:___________________________

Revised: October 1999