Board of Certified Safety Professionals
2301 W. Bradley Avenue Champaign, Illinois 61821 P: +1 217-359-9263 | F: +1 217-359-0055 E: bcsp@bcsp.org | W: www.bcsp.org
Certified Safety Professional
APPLICATION FORM
See the CSP Application Guide instructions for completing this form. View and print additional copies at www.bcsp.org/csp.
APPLICANT PERSONAL DATA
NAME
Mr.
Ms.
First
MI
Last/Family
Maiden Name (if applicable)
Other Legal Name (if applicable)
HOME ADDRESS
U.S. SOCIAL SECURITY NUMBER
Street Address Apartment Box Number
DATE OF BIRTH (MM/DD/YY)
City State/Province
NAICS CODE (See Table 2)
Zip/Postal Code
Country 1. 2.
PHONE NUMBERS
(If outside the U.S. or Canada, include country and city codes)
HOME PHONE (Area Code & Number)
WORK PHONE (Area Code & Number)
CELL PHONE (Area Code & Number)
FAX (Area Code & Number)
EMAIL ADDRESS(ES)
COLLEGE EDUCATION
(The minimum qualification is either an associate degree in safety, health and the environment or a bachelors degree in any field.) GRADUATION DATE (MM/DD/YY) PROGRAM OF STUDY OR MAJOR DEGREE EARNED TRANSCRIPT (Check one) Enclosed School is sending Enclosed School is sending Enclosed School is sending Enclosed School is sending
COLLEGE OR UNIVERSITY (Name, City, State)
SUMMARY OF PROFESSIONAL SAFETY EXPERIENCE (You must complete a Professional Safety Experience Form for each position
listed below for which you are seeking credit. Do not overlap time periods.)
START DATE (MM/YY) END DATE (MM/YY) POSITION TITLE (List the most recent first) EMPLOYER MONTHS IN POSITION
TOTAL MONTHS
PROFESSIONAL REFERENCES
PROFESSIONAL REFERENCE
List only individuals who are providing a Reference Form. Two professional references are required.
TITLE RELATIONSHIP REFERENCE Enclosed Sending Enclosed Sending
CERTIFICATIONS, LICENSES, AND MEMBERSHIPS
(Check all that you currently hold. Please submit a copy of your original certificate. BCSP will verify whether you are in good standing.)
COHN-S/SM Eligibility credit (12 points max): OHST CHST
Safety Fundamentals Waiver: CIH CHP P.E. (specify state) ___________ CEng (UK) COHN/SM CMIOSH CPMSIA/FSIA/CFSIA CRSP
SISO (Professional Member with current status as a Workplace Safety and Health Officer with the Singapore Ministry of Manpower)
PROFESSIONAL SOCIETY MEMBERSHIPS
ASSE AIHA SFPE IIE SSS
(Check all current memberships.)
NSC ACGIH (Individual member) HPS NSMS HFES NFPA NESHTA
SAFETY SPECIALTIES
Occupational Safety System Safety Construction Safety Transportation Safety General Safety Fire Protection Process Safety Industrial Hygiene Product Safety Environmental Radiation Protection Training Other _______________________
VALIDATION
1. 2. 3. 4.
(You must answer the following questions. Be sure to sign and date your application or it cannot be processed. Your signature means you agree with the following statements; and if paying by credit/debit card, authorize the charges to be made to your account.)
Have you ever been convicted of a felony? YES NO Have you been convicted of a misdemeanor within the last 5 years? YES NO Do you have a record of any unethical behavior? YES NO Have you ever had a professional registration, license or certification denied, suspended or revoked other than for lack of minimum qualifications, failure of examination, or failure to pay renewal fees? YES NO
(If you answered YES to any of the questions 1-4, you must complete the Criminal Conviction & Professional Registration, Certification or License Information Form available at www.bcsp.org/pdf/ccform.pdf). 5. I understand that any falsification of information in this application including any attachments or supplemental materials, provided now or later, may be cause for rejection or withdrawal of certification or such other action as the Board of Certified Safety Professionals shall deem appropriate. I certify that the statements above (including any attachments submitted, now or later) are accurate to the best of my knowledge. I hereby authorize the Board of Certified Safety Professionals to verify any information or supplements submitted.
I further agree to hold the Board of Certified Safety Professionals harmless from any and all liability in the event this application is rejected on the basis of information furnished to the Board by me or third persons which would, in the judgment of the Board, make me ineligible for certification. With this application, I hereby authorize the Board of Certified Safety Professionals to publish in all of its directories or registries my name, city, state, country, and any certification it issues to me. The Board of Certified Safety Professionals will make every effort to keep your personal and examination information confidential. The Board of Certified Safety Professionals will obtain your approval prior to releasing information from your Board of Certified Safety Professionals records, other than directories, verification of your certification to the public or a court subpoena for your records. I further agree to adhere to the Board of Certified Safety Professionals BCSP Code of Ethics and Professional Conduct in its current and subsequent editions and, if I am certified, to meet the requirements for Recertification. _____________________________________________ Applicant Signature (in ink) www.bcsp.org/pdf/BCSPcodeofethics.pdf
________________ Date
APPLICATION PAYMENT INFORMATION
$160 FEE PAID BY
Check or Money Order
(The application fee is nonrefundable and nontransferable.) CREDIT/DEBIT CARD AUTHORIZATION
Credit/Debit Card Number Expiration Date M M Y Y
(U.S. dollars only) Make checks payable to:
BCSP
American Express Discover/Novus MasterCard VISA
Name (as it appears on card) Signature
CVV/CVV2
Billing Address
BCSP PROFESSIONAL ADVANCEMENT MENTOR PROGRAM (This is an optional program. If participating, form must be attached. Form is at www.bcsp.org/mentoring.)
1/2013
SPONSOR NAME____________________________________________________
APPLICATION ACCEPTED________________________
