NASPCB Volunteer Application

Please check which of the following you are most interested in:(Required)

NASPCB Board of Advisors

Knowledge and Skills Committee

Item Writing Committee

Examination Committee

Appeals/Complaints Committee

NASPCB Outreach Committee

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone(Required)

Work Phone

Cell Phone

Home Phone

Email(Required)

Demographic Information

Demographic Information: This section is not optional. Volunteers completing this form must hold a High School Diploma or GED. This section is used to gather the demographic make-up of our volunteers.

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Other

Prefer not to answer

Please Specify if Other

Education(Required)

High School or GED

Some college credit, no degree

Associate degree

Bachelor’s degree

Master’s degree

Doctorate degree

Special Skills

Current Job Title(Required)

Current Company(Required)

Years of Experience in Safety (Minimum requirements are 6 years in OHS or EHS, and 50% of the current role is in safety)(Required)

Company Industry(Required)

Primary Safety Specialty(Required)

Current Credentials Held(Required)

Certified Safety Manager (CSM)

Certified Safety Director (CSD)

Safety Director Certificate (SDC)

Licensed Safety Professional (LSP)

Safety Professional Certificate (SPC)

Master Safety Professional (MSP) Credential

Certified Safety Director (CSD) Credential

Other

Please list other credentials held

Are You a Veteran?(Required)

Yes

Background Disclosure

NASPCB may obtain arrest and conviction records and reported unethical behavior on all potential volunteers. An arrest or conviction will not automatically eliminate you from consideration for volunteering. However, failure to list all pending charges and/or convictions may lead to your disqualification or termination of volunteering with NASPCB. Examples may include, but not limited to: driving while impaired, worthless checks, assault, driving while license is suspended, disorderly conduct, credit card fraud, embezzlement, etc.

Have you ever been convicted of any criminal violation of law, or are you now subject to a pending investigation of charges for violation of criminal law?(Required)

Yes

Please explain

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

Yes

Please explain

Do you have a record of any unethical behavior?(Required)

Yes

Please explain

Confidentiality

Confidentiality: If accepted as a volunteer, I understand I will be required to sign and uphold the NASPCB Code of Ethics, Non-Disclosure, and Conflict of Interest Agreements.

Volunteer Agreement

As a volunteer, I understand and agree:

My services are donated to NASPCB without contemplation of compensation or future employment.
Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age, gender or sexual orientation.
Completing a volunteer application does not guarantee placement given the number of applicants may exceed the number of available openings and must be approved by the NASPCB Board of Advisors.
The information provided is accurate and verification shall be provided upon request.
By checking ‘I agree’ this serves as your agreement and attestation of the statements in this volunteer agreement.

I agree(Required)

Yes

Name(Required)

First Last

Signature(Required)

Time(Required)

Date(Required)

This field is for validation purposes and should be left unchanged.

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