BCRSP/BCSP

RECIPROCAL AGREEMENT

APPLICATION FORM

Under the Memorandum of Understanding between the BCRSP and the BCSP, applicants holding the CSP certification and seeking the CRSP certification need only submit this completed application form, non-refundable application fee and successfully pass the CRSP Examination (CRSPEX).

Part A: Applicant Personal Information
Salutation / MrMrsMsDr (Please select via drop down list)
Last Name
First Name
Employer
Your Position/Title
Business Address
City
Province/State
Postal/Zip Code
Business Telephone / ()
Email
Home Address
City
Province/State
Postal/Zip Code
Home Telephone / ()
Preferred Mailing Address / Business Home
It is the applicant’s responsibility to keep the Board informed of any changes to the above information.
Part B: CSP Designation Data
CSP Registration No.
Please attach a copy of certificate or other documentation verifying designation)
Date Designation Obtained
Part C: Other Current Professional Licenses, Registrations And Certifications (Check All That Apply.)
CIH PE CHP OHST CHST CEng SISO CMIOSH Other
Part D: Validation
  1. Have you ever had professional registration or certification denied, suspended or revoked other than for lack of minimum qualifications or examination failure?
YesNo(If answer is YES, explain fully on separate sheet)
I understand that to receive the CRSP designation under the BCRSP/BCSP Memorandum of Understanding, I will be required to pass an examination (CRSPEX). I understand the examination is a computer based test (CBT) based on the Examination Blueprint and administered at third party test centres contracted by the Board.
  1. 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 Canadian Registered 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 Canadian Registered Safety Professionals to verify any information or supplements submitted.
I further agree to hold the Board of Canadian Registered Safety Professionals harmless from any and all liability in the event this application is rejected on the basis of information furnished to the Board of Canadian Registered Safety Professionals by me or third parties thatwould, in the judgement of the Board, make me ineligible for certification.
Although every effort will be made to keep my application confidential, I understand that the Board of Canadian Registered Safety Professionals is under no obligation to keep confidential any statements, material, information, etc. that I submit.
I further agree to adhere to the Board’s Code of Ethics and to meet the requirements of the Certification Maintenance Program if I am registered.
Signature:
Date:

A non-refundable application fee of $175.00 + applicable HST/GST taxes (if applicable)in Canadian (or U.S. equivalent) funds must accompany your application.

Make cheque/money order payable to the

BOARD OF CANADIAN REGISTERED SAFETY PROFESSIONAL or BCRSP

Application Fee Credit Card Payment:

Name of Applicant:Province/State of Residence:

Payment By: American Express MasterCard Visa

Card # Cardholder’s Name:

Expiry Date:

I authorize a $175.00 + HST/GST charge (if applicable) to the credit card noted above.

Signature:

Note: The Memorandum of Understanding (MOU)between BCRSP and BCSP does not require individuals holding the CSP to complete a Reference Questionnaire, Practice Questionnaire or meet the current educational standards for the CRSP. The MOU states that someone holding the CSP and applying for the CRSP must complete this Application Form and pass the CRSPEX in order to achieve the CRSP. The BCRSP agreed to accept the qualifications already evaluated by the BCSP in the CSP certification process.

Doc.119

Last Review: February 2012