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: ESAM AHMADS ABDULRAHMAN ALSAMARAEE………………………………………….

2. Registration No.: FG10………………………………………

3. Business Address (if there is any change)

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

SAME AS BEFORE........................…………………………………………………......….
………………………………………………………………………………………………….
………...............................................................................................................………..
………............................................................................................................................

Tel. no.: 019-3351690………………… Fax no.: 03-41613716……………...........

E-mail address: asumi13@gmail.com……………………………...................................

4. Details and proof of payment enclosed:

*online via maybank2u from account no. 114124006846 SA transaction date 08/12/2019

for RM1000..........................

[All payments in cash or internet banking/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 year
.2020 I confirm that the information given in this form is true, complete and accurate.

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

Date.......8th Dec.2019................

*Delete whichever is not applicable