INITIAL APPLICATION for CERTIFICATION Or REGISTRATION

APPLICATION FOR NQI CERTIFIED EXCELLENCE PROFESSIONAL

LEVEL 1, 2 & 3 Application form

Please complete all required sections of the application. Incomplete applications may result in a delay of your application being processed. Where supplemental information or additional space is required, please assign and clearly mark an attachment number on each supporting document and record that number in the appropriate places provided on this form.

Please type or clearly print all entries in black or blue ink.

APPLICANT

Title:Mr., Mrs., Ms., Dr. (please circle or enter another): ______

______

Applicant’s surname ( family or last name ) Given ( first name ) Initials

______

Please enter your name as you wish it to appear on all correspondence and/or documentation

ADDRESSES

______

Company/Organization Name

______

Street address and/or P. O. Box #

______I______

CityProvince

______I______

CountryPostal

______I______

Tel: #Fax: #

e-mail address: ______

APPLYING TO:

  Level 1 Level 2 Level 3

CURRENT CERTIFICATION Attachment #’s______

List any current NQI Certifications if applicable.

______

Certification Certificate Number

______

Issue DateExpiration Date

DIRECTORY OF NQI CERTIFIED EXCELLENCE PROFESSIONALS

I agree to the publication in the NQI Directory of Certified Excellence Professionals of my name, company affiliation, address, tel/fax numbers: Yes_____ No_____

EDUCATION Attachment #’s______

Indicate the highest education level attained and attach a copy of this degree, diploma or equivalent document(s). Please provide copies of degree(s)/diploma(s)/certificate(s) to confirm your level of education.

 Bachelor’s degree ( or higher ) Associate’s degree/diploma (or equivalent)  Other Post Secondary education

Master’s Degree ( or equiv. ) Secondary school diploma/certificate (or equivalent)

______

Graduation date# of Yrs/MthsUniversity/College/Secondary or Other InstitutionDegree/Diploma/Certificate/Grade

WORKPLACE EXPERIENCE (REQUIRED FOR LEVEL 3 Application Only)Attachment #’s______

Starting with your current position, list below employment or consulting experience in the related field (i.e. Quality, Healthy Workplace). Enter the # of experience months on the EXP. Line. Use a numbered attachment for additional entries.

Please note present and/or past employers and/or clients may be contacted to verify your relevant work experience.

1.______2.______

Company NameCompany Name

______EXP______EXP____

Position TitlePosition Title

______I______I______

FromTo Type of BusinessFromTo Type of Business

______

DutiesDuties

______

______I______I______I______I______

Supervisor’s Name Telephone Fax NumberSupervisor’s Name Telephone Fax Number

e-mail address: ______e-mail address: ______

3.______

Company Name

______EXP____

Position Title

______I______

FromTo Type of Business

______

Duties

______

______I______I______

Supervisor’s Name Telephone Fax Number

e-mail address: ______

NQI TRAINING Attachment #’s______

Please provide copies of certificates or documentation to confirm that you have successfully completed the NQI courses and requirements listed below. The course must have been completed within three years of applying for certification.

NOTE: If you have previously applied and received Level One and Level Two,you do not need to resubmit copies of the certificates or documents required for those levels.

() / ()
LEVEL 1

Quest for Quality - Module 1 - Online Learning

Introduction to the Framework for Excellence - Online Learning

Framework for Excellence

Introduction to the Healthy Workplace Criteria - Online Learning

Business Fundamentals - Online Learning

LEVEL 2

Quest for Quality: Process Improvement Tools (Modules 2 & 3)

Healthy Workplace Implementation Workshop

Introduction to Process Mapping

Introduction to Root Cause Analysis

Introduction to Change Management - Online Learning***

Management and TeamBuilding - Online Learning***

Customer Service - Online Learning***

Time Management Strategies for Success - Online Learning***

Operations Management - Online Learning***

Workplace and Personal Skills - Online Learning***

LEVEL 3

Organizational Excellence Assessment

Operational Process Mapping

Statistical Quality Tools

Operational Root Cause Analysis

Measuring Customer/Stakeholder Satisfaction

Interactive Assessor - Game Based Learning

Management & Supervisory Skills - Online Learning

Human Resources - Online Learning

Quality Customer Service - Online Learning

Introduction to Balanced Scorecard - Online Learning

Equivalencies or exemptions based on previous course work are assessed on a case by case basis. On the recommendation of the CEP Committee, participants may be granted equivalencies or exemption, to a maximum of five (5) courses for all levels of the program. Please complete the CEP Equivalency form available at

ENDORSEMENTS (REQUIRED FOR LEVEL 3 Application Only) Attachment #’s______

Each applicant (Level 3 only) must be sponsored by either: two existing Managers/Peers. Please list the sponsors' contact information.

1.______2. ______

Sponsor’s Name Sponsor’s Name

______

Company NameCompany Name

______

Tel. # Tel. #

E-mail address: ______E-mail address: ______

Thank-you for your application

Page 1 of 4 Published by NQI - May 12, 2006 NQI FORM 3