CSD Additional Information Request Name (as it appears on your government issued identification)(Required) First Middle Last Email(Required) Highest Level of Education(Required)High SchoolAssociates DegreeBachelors DegreeGraduate DegreeWhat Discipline(Required) Current Credentials Please select the credential(s) that you currently hold and enter the certification or certificate number(s).Certified Safety Manager (CSM) Certified Safety Manager (CSM) Certification Number(Required) Certified Safety Director (CSD) Certified Safety Director (CSD) Certification Number(Required) Licensed Safety Professional (LSP) Licensed Safety Professional (LSP) Certification Number(Required) Safety Director Certificate (SDC) Safety Director Certificate (SDC) Certification Number(Required) Safety Professional Certificate (SPC) Safety Professional Certificate (SPC) Certification Number(Required) Certified Safety Professional (CSP) Certified Safety Professional (CSP) Certification Number(Required) Associate Safety Professional (ASP) Associate Safety Professional (ASP) Certification Number(Required) NEBOSH National or International Diploma in Occupational Health and Safety NEBOSH National or International Diploma in Occupational Health and Safety Certification Number(Required) Construction Health and Safety Technician (CHST) Construction Health and Safety Technician (CHST) Certification Number(Required) Occupational Health and Safety Technician (OHST) Occupational Health and Safety Technician (OHST) Certification Number(Required) Safety Trained Supervisor (STS) Safety Trained Supervisor (STS) Certification Number(Required) Certified Safety and Health Manager (CSHM) Certified Safety and Health Manager (CSHM) Certification Number(Required) Canadian Registered Safety Professional (CRSP) Canadian Registered Safety Professional (CRSP) Certification Number(Required) Safety Management Specialist (SMS) Safety Management Specialist (SMS) Certification Number(Required) State-Sponsored/Recognized EHS Certificate Program State-Sponsored/Recognized EHS Certificate Program Certification Number(Required) Employment InformationJob Title(Required) Total Years of Experience(Required)Current Employer(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor Name(Required) Supervisor Email(Required) Start Date(Required) MM slash DD slash YYYY End Date MM slash DD slash YYYY Percent of Job in Workplace SafetyLess Than 25%25%50%75%100%Number of Employees in Facility1-5051-100100-200200+How Many FacilitiesCompany IndustryAgriculture/Forestry/Fishing/HuntingMining/Quarrying/Oil/GasUtilitiesConstructionManufacturingWholesale TradeRetail TradeTransportation/WarehousingInformationFinance/InsuranceReal Estate/Renting/LeasingProfessional/Scientific/Testing ServicesManagementWaste Management/RemediationEducationalHealth Care/Social ServicesArts/Entertainment/RecreationAccommodations/Food ServicesPublic AdministrationPrimary Safety SpecialtyOccupational SafetyConstruction SafetyGeneral SafetyProcess SafetyProduct SafetySystem SafetyTransportation SafetyFire ProtectionIndustrial HygieneEnvironmentalPrevious Employer (if current job does not meet the minimum professional safety experience as indicated on the CSD Track). If you begin this section, please complete all fields and include Supervisor Name and Supervisor Email.Company Name Job Title Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor Name Supervisor Email Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Percent of Job in Workplace SafetyLess Than 25%25%50%75%100%Number of Employees in Facility1-5051-100100-200200+How Many FacilitiesCompany IndustryAgriculture/Forestry/Fishing/HuntingMining/Quarrying/Oil/GasUtilitiesConstructionManufacturingWholesale TradeRetail TradeTransportation/WarehousingInformationFinance/InsuranceReal Estate/Renting/LeasingProfessional/Scientific/Testing ServicesManagementWaste Management/RemediationEducationalHealth Care/Social ServicesArts/Entertainment/RecreationAccommodations/Food ServicesPublic AdministrationPrimary Safety SpecialtyOccupational SafetyConstruction SafetyGeneral SafetyProcess SafetyProduct SafetySystem SafetyTransportation SafetyFire ProtectionIndustrial HygieneEnvironmentalPrevious Employer (if current job does not meet the minimum professional safety experience as indicated on the CSD Track). If you begin this section, please complete all fields and include Supervisor Name and Supervisor Email.Company Name Job Title Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor Name Supervisor Email Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Percent of Job in Workplace SafetyLess Than 25%25%50%75%100%Number of Employees in Facility1-5051-100100-200200+How Many FacilitiesCompany IndustryAgriculture/Forestry/Fishing/HuntingMining/Quarrying/Oil/GasUtilitiesConstructionManufacturingWholesale TradeRetail TradeTransportation/WarehousingInformationFinance/InsuranceReal Estate/Renting/LeasingProfessional/Scientific/Testing ServicesManagementWaste Management/RemediationEducationalHealth Care/Social ServicesArts/Entertainment/RecreationAccommodations/Food ServicesPublic AdministrationPrimary Safety SpecialtyOccupational SafetyConstruction SafetyGeneral SafetyProcess SafetyProduct SafetySystem SafetyTransportation SafetyFire ProtectionIndustrial HygieneEnvironmentalThe NASP/IASP, Inc. Certification Board (NASPCB) has the right to evaluate the character of applicants, candidates, and Certificants of the NASP/IASP, Inc. Certification Program. The NASPCB considers criminal conviction history and known unethical behaviors of each applicant, candidate, and Certificant of the NASP/IASP, Inc. Certification Program. If you answer “Yes” to #1, please fill out and upload the Criminal Convictions and Unethical Behavior Form. Click here for a copy of the form.Have you ever been convicted of a felony?(Required) Yes No If Yes, Please List:(Required)Have you been convicted of a misdemeanor within the last five (5) years?(Required) Yes No If Yes, Please List:(Required)Do you have a record of any unethical behavior?(Required) Yes No If Yes, Please List:(Required)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?(Required) Yes No If Yes, Please List:(Required)Your signature below gives consent to the NASPCB to verify all information provided in this form to include but not limited to the stated education (diploma and transcripts or academic record(s) showing degree/s earned and date granted), credential(s) held, employment history, and criminal conviction history and known unethical behaviors. Your signature also indicates you agree to the Code of Ethics and Non-Disclosure Agreement found at the bottom of this page. By typing your name, this serves as your electronic signature. You agree your electronic signature is the legal equivalent of your manual signature on this application.Signature(Required) By checking this box, you are attesting that you have received, read, fully understand and consent to the Certificant’s Code of Ethics and Professional Standards Agreement, Candidate’s Non-Disclosure and Confidentiality Agreement, and Criminal Conviction and Unethical Behavior Agreement as set forth by the NASP/IASP, Inc. Certification Board.(Required) Confirm NASP/IASP, Inc._Certificant’s Code of Ethics and Professional Standards, Examination Non-Disclosure and Confidentiality, Criminal Conviction and Unethical Behavior Agreement FormFile(Required) Drop files here or Select files Max. file size: 64 MB, Max. files: 10. Please upload the supporting document/s showing that you currently hold the certification/s as indicated. Please upload a copy of an official diploma and official transcript or academic record(s) showing degree earned and date granted for High School or Higher Education. The NASPCB will accept a copy of an official transcript. Non-U.S. degree holders are required to have their academic records evaluated for U.S. equivalency. Documents that are not issued in English must be accompanied by an official or certified English translation. The NASPCB will need to verify your official diploma and official transcript or academic record(s). In addition to uploading these documents, please request your academic provider/verifier (High School and/or Higher Education) to send verification directly to the NASPCB Attn: Teresa Amey NASPCB Certification Coordinator at [email protected] If your academic provider (High School and/or Higher Education) directly permits third parties to verify the official diploma and official transcript or academic record(s), please email [email protected] and provide the contact information. Δ
