UTAH GEOLOGICAL ASSOCIATIONMembership Form

The dues period begins October 15 each year. Deadline for the membership directory is December 31. Send the completed form to UGA, P.O. Box 520100, Salt Lake City, UT 84152-0100

RenewalMembership Type: ______________

New Member

Last Name First Name Middle Initial

Company Name Title

Work Address

City State Province/Country

Postal Code Work Phone Work Fax

Email Address

Home Address

City State Province/Country

Postal Code

EDUCATION

Home Phone Work Address Preferred Home Address Preferred

Institution Degree Year Received

I am interested in serving:

On a UGA committee

As a UGA elected officer

Active or Associate Member: $20 ______ Associate Student: $5 ______

Emeritus or Honorary (no dues required) ______ Life Member (one-time payment): $250 ______

Donation to Student Scholarships(suggested minimum $5; Not Tax Deductible) ______

TOTAL _

Major

Date: ______________

Year Joined: ______________

DUES ASSESSMENT:

(please provide details on page 2 C, D, & E)

UGA Member Professional Profile, 2013 Please return with your dues statement and check

A. Professional area(s) of specialty (check all that apply)

Economic Geology

EnvironmentalFossil Fuel E & PGeochemistryGeoengineering GeohazardsGeologic Mapping

B. Professional employment (select only one)

Federal Government State Government City/County Government Higher Education

Student

Geophysicist/SeismicManagement/PlanningMiningRenewable EnergyPaleontologyHydrogeology/Water ResourcesSedimentology/StratigraphyOther ___________________

Fossil Fuel Company Mining Compan y Consulting Firm Independent Consultant

Other___________________

Environmental Affairs Geologic Road Signs HistoryMembership

Publicity

C. Serving on a committee (check all that interest you)

D. Running for office (check all that interest you)

President (3 yrs; president-elect, president, past-president)

TreasurerSecretaryProgram Chair

E. Volunteer Opportunities (check all that interest you)

K-12 Education Retired

Education/Scholarship Public EducationPublications

Social/Recreation

Meeting set-up/take-downSpeak at schools (education committee)

Education