CSD Additional Information Request

Name (as it appears on your government issued Identification) *

First

Middle

Last

Email *

Highest Level of Education *

What Discipline *

Current Credentials

Please select the credential(s) that you currently hold and enter the certification or certificate number(s).

Certified Safety Manager (CSM)

Certification Number *

Certified Safety Director (CSD)

Certification Number *

Licensed Safety Professional (LSP)

Certification Number *

Safety Director Certificate (SDC)

Certification Number *

Safety Professional Certificate (SPC)

Certification Number *

Associate Safety Professional (ASP)

Certification Number *

NEBOSH National or International Diploma in Occupational Health and Safety

Certification Number *

Construction Health and Safety Technician (CHST)

Certification Number *

Occupational Health and Safety Technician (OHST)

Certification Number *

Safety Trained Supervisor (STS)

Certification Number *

Certified Safety and Health Manager (CSHM)

Certification Number *

Canadian Registered Safety Professional (CRSP)

Certification Number *

Safety Management Specialist (SMS)

Certification Number *

State-Sponsored/Recognized EHS Certificate Program

Certification Number *

Employment Information

Job Title *

Total Years of Experience *

Current Employer *

Address 1 *

Address 2

City *

State *

Province

Postal Code *

Country *

Supervisor Name *

Supervisor Email *

Start Date *

End Date

Percent of Job in Workplace Safety *

Number of Employees in Facility *

How Many Facilities *

Company Industry *

Primary Safety Specialty *

Previous 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 1

Address 2

City

State

Province

Postal Code

Country

Supervisor Name

Supervisor Email

Start Date

End Date

Percent of Job in Workplace Safety

Number of Employees in Facility

How Many Facilities

Company Industry

Primary Safety Specialty

Previous 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 1

Address 2

City

State

Province

Country

Postal Code

Supervisor Name

Supervisor Email

Start Date

End Date

Percent of Job in Workplace Safety

Number of Employees in Facility

How Many Facilities

Company Industry

Primary Safety Specialty

The 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? *

Yes
No

If Yes, please list *

Have you been convicted of a misdemeanor within the last five (5) years? *

Yes
No

If Yes, please list *

Do you have a record of any unethical behavior? *

Yes
No

If Yes, please list *

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 Yes, please list *

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 *

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. *

Confirm

NASP/IASP, Inc._Certificant’s Code of Ethics and Professional Standards, Examination Non-Disclosure and Confidentiality, Criminal Conviction and Unethical Behavior Agreement Form

File Upload *

Click or drag files to this area to upload. You can upload up to 30 files.

*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.