Professional Documents
Culture Documents
QUALIFICATION REFERENCE
(Pleasemakeasmanycopiesofthisformasnecessarytoprovidethe
appropriatenumberofQualificationReferencesneeded)
APPLICANT:CompleteItemsD.1,D.2,andD.3thenforwardthisformtothepersonyouhavelistedin
ItemD.3.AskthispersontocompletetheremainderoftheformandreturnitdirectlytoNACE
InternationalInstitute.
Qualificationreferencesmaybesubmittedbythefollowing,whichhaveexpertiseinthecorrosionfield
andcanverifytherequiredfield/instrumentationexperience:
Registeredorcharteredengineers
Presentand/orprevioussupervisor(s)oftheapplicant
P.M.ofthereferredProject
NACEInternationalInstitutecertificateholders(ForCIPLevel3applicants,oneQualification
ReferencemustholdaNACEInstituteCertificateatthelevelbeingappliedfor.)
D.1 ApplicantsFullName:
D.1A NACEMemberID#:
D.2 Certificationcategoryappliedfor:
D.3 Name,title,companyname,address,andphonenumberofpersonwhoisfamiliarwiththe
workexperienceoftheapplicant:
Phone:
REFERENCE:TheapplicantisapplyingforprofessionalrecognitionbyNACEInternationalInstitute.
Applicantsforcertificationmustmeetspecificrequirements;pleaseseethelistoftheserequirements
onthefollowingpage.Evaluationofanapplicantsqualificationsalsodependsonassessmentof
professionalexperiencebyreferences.ItisrequestedthatyoucompleteItemsD.4throughD.13onthis
formandreturnitdirectlytoNACEInstitute.
D.4 IholdNACEInstituteCertificationasa:
(Leavethissectionblankifthissectionisnotapplicable)
Certified No.
IamaRegisteredEngineer(orequivalent)
State/Province: Branch: No:
D.5 Ihaveknowntheapplicantforyears.Whatis/wasthenatureoftheassociation?
CurrentSupervisor PreviousSupervisor
CurrentClient PreviousClient
CurrentCoworker PreviousCoworker
CurrentProfessor/Instructor PreviousProfessor/Instructor
Other(Pleasespecify)
D.6 Frompersonalknowledge,myassessmentoftheapplicantscharacterandpersonalreputation
isthatitis:
D.7 Frompersonalknowledge,Iknowthattheapplicanthasbeenengagedinthefieldofcoatings
relatedfieldworkforyears.(Definedascoatingsrelatedfieldworkinanindustrialsettingwhere
protectivecoatingsareinspected).
D.8 Basedonthispersonalknowledge,Iknowthatthequalityoftheapplicantsworkinthefieldof
Coatingsis
D.9 Theapplicantisproficientinthefollowingphasesofcoatingsinspection:
D.10 Wouldyouemploy,orrecommendtheemploymentof,theapplicantforemploymentinthe
phaseofcoatinginspectionyouhavedescribedinItemD.9?
Yes No
NACEInternationalInstituteCertificationProgram
D.11 PleasedescribeINYOUROWNWORDSanymajorprojects/activitiesinwhichtheapplicanthas
beeninvolvedinthefieldofcoatingsinspectionwork.Describeonlythosewhereyouhad
personalknowledgeoftheapplicantswork.Pleaseindicatethedegreeofresponsibility
exercisedbytheapplicant,thecomplexityoftheproject/activity,thename/sandtype/softhe
project/s,thedegreeofknowledge/skillrequired,etc.
(Youcanattachaseparatesheetifyouwish,orifyouneedmorespace).
**THED.11SECTIONMUSTBECOMPLETEDBEFORETHE
APPLICATIONCANBESUBMITTEDFORREVIEW**
D.12 Anyadditionalremarksyouwouldliketoaddconcerningthisapplicant:
D.13 MysignaturebelowindicatesthatIhavepersonalknowledgeandexpertiseinthecorrosion
fielduponwhichtoevaluatetheapplicantsprofessionalcapabilities.
Signature: Date:
PrintedName:
Thecompletedformcanbereturnviaemailorregularmail:
NACEInternationalInstitute
CertificationDepartment
15835ParkTenPlace
Houston,TX77084USA
Email:cipapplications@nace.org
NACEInternationalInstituteCertificationProgram