MEMBERSHIP APPLICATION FORM

MEMBERSHIP  Corporate  Individual

NAME OF COMPANY________________________________________________________________
NAME OF REPRESENTATIVE __________________________________________________________
ADDRESS ___________________________________________________________________________
TEL. NO. _________________________________ FAX NO. _________________________________
MOBILE NO. _____________________________ EMAIL ADDRESS: _________________________
PLEASE CHECK PROPER BOX:
 WELL DRILLING CONTRACTOR  PUMP CONTRACTOR
 WATER TREATMENT CONTRACTOR  WHOLESALE SUPPLIER
 MANUFACTURER’S REPRESENTATIVE  GROUNDWATER PROFESSIONAL
 GOVERNMENT OFFICIAL  MANUFACTURER
 WATER SYSTEM OPERATOR  OTHERS pls. specify _______________

SPECIALIZATION INFORMATION
1. Contractors complete this section:

 Full-service contractor  Pump only contractor

 Drilling only contractor  Irrigation
 Student (enter area of study)  Other contractor (please indicate)
___________________________ __________________________

2. Wholesale suppliers and distributors of drilling equipment, pumps, and water well treatment
complete this section:

 Supplier, full service groundwater  Management Services

 Irrigation  Supplier, other _________________

3. Manufacturers of drilling equipment, pumps, water well supplies and water conditioning
equipment complete this section:

 Management  Sales Personnel

 Manufacturer’s representative  Company
 Irrigation  Other’s, please specify ______________

4. Operators of ground-water supplied community water systems complete this section:

 Management  Operator
 Others, please specify ___________________

______________________________ _________________
SIGNATURE OVER PRINTED NAME DATE

Phil. Groundwater Society Inc. 2nd Flr. Epsilon Chi Center Balagtas St. cor. Magsaysay Ave., UP Campus, Diliman, Quezon  +63915-101-9275
philgroundwatersociety@gmail.com