BOARD OF GEOLOGISTS MALAYSIA

FORM F

GEOLOGISTS ACT 2008

GEOLOGISTS REGULATIONS 2015

Subregulation 3(2)

APPLICATION FOR RENEWAL OF CERTIFICATE OF REGISTRATION

as a
*Registered Graduate Geologist / Registered Professional Geologist /
Registered Practitioner / Registered Foreign Geologist

1. Name: …….…………………………………………………………………………………….

2. Registration No.: ………………………………………

3. Business Address (if there is any change)

[Section 32 Geologists Act 2008 - Notification of change of address]

…………………...............................…………………………………………………......….
………………………………………………………………………………………………….
………...............................................................................................................………..
………............................................................................................................................

Tel. no.: ………….……………………… Fax no.: ….…..........………………...........

E-mail address: ..................………………………………………...................................

4. Details and proof of payment enclosed:

*Cash/Internet Banking/CDM/Money Order/ Bank Draft/ Cheque no............................

for RM.............................

[All payments in cash or internet banking/CDM/money order/ bank draft/cheque made

payable to ‘Lembaga Ahli Geologi’ Maybank Account No. 5640-5252-2670. Proof of
payment must be submitted together with this form.]

I hereby apply for renewal of registration as a *Registered Graduate Geologist / Registered

Professional Geologist / Registered Practitioner / Registered Foreign Geologist for the
2022............... I confirm that the information given in this form is true, complete and
year
accurate.

…………………………………………
Signature of applicant
Stamp:

Date.........................................

*Delete whichever is not applicable