Image '25

Contact Information

*Priority Code:
*Name of Host Organization:
*First Name/Forename:
*Last Name/Surname:
Job Position/Title:
*Company/University:
Cell Phone
Cell Phone
Please provide your mobile device number to help facilitate communications in the case of an emergency. By entering in your mobile phone number, you agree to receive messages via SMS/MMS.
*Email:
Address Line 1:
Address Line 2:
*City:
*Zip/Postal Code (if not applicable, please enter 00):
*State:
*Country of Residence:
Country of Citizenship:
Primary Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Cell Number:
List any Medical Conditions/Allergies you may have:
*Click here to indicate that you have read and will comply with IMAGE's Code of Conduct

Demographic Information

*Member of the following? (Check all that apply)
American Association of Petroleum Geologists (AAPG) Society of Exploration Geophysicists (SEG)
Society for Sedimentary Geology (SEPM) None of the above
*Which best describes your profession:
Geologist Geophysicist
Engineer Landman
Petrophysicist Economist/Financier
Academic Marketing/Sales
Technician Student
Other
Please specify
*Job Title:
Consultant
Staff Geophysicist
Staff Geologist
Engineer
Chief Geophysicist
Chief Geologist
Manager/Director
Vice President
President/CEO
Student
Retired
Other
Please specify
*Industry Sector: Which sectors do you most closely associate with? (Check all that apply)
Oil & gas
CCUS
Geothermal
Hydrogen
Other renewables
Technology/digital
Earth sciences general (e.g., geology, geophysics, etc.)
Academia
Government
Non-profit
Mining/Mineral Exploration
Environmental Geophysics
Near Surface Geophysics
Engineering Geophysics
Other
Please specify
*Age
*Race/Ethnicity:(Check all that apply)
Asian or Asian American
Black, African, African-American or Afro-Caribbean
Hispanic, Latinx, Latino, Latina, or Spanish Origin
Indigenous Peoples
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Native of Indian Subcontinent
White, Euro-American, or European
Not listed
Prefer not to answer
*Gender:
What (if any) are your special needs? (Check all that apply)
Wheelchair Rental
Vegetarian/Vegan
Wheelchair Accessible
Gluten Free
Other Dietary
Please specify
*Do you wish to receive further communication from IMAGE regarding specific event information or future event information
I am interested in attending the Inaugural C-Suite Strategic Panel; Global Upstream for the 2030’s, sponsored by Wood Mackenzie; Monday, 25th August 1:30 p.m.- 4:30 p.m.

There are errors in your form, see details above!

Powered by TPNI - The Pulse Network - www.tpni.com