CPEA Professional Reference Questionnaire (PRQ) Step 1 of 4 - Applicant Data 25% THIS QUESTIONNAIRE IS TO BE COMPLETED BY THE REFERENCE ONLY Directions: This is the online form to submit a professional reference for an individual applying for the Certified Professional Environmental Auditor® (CPEA®) or Certified Process Safety Auditor® (CPSA®) credential. As part of the application, two references are required from the applicant's supervisor, manager, educator, or other individual who has known the applicant a minimum of two years and who is familiar with the applicant's skills and attributes as they relate to environmental auditing, environmental compliance, and integrity. An applicant’s spouse, other relatives, or a person whom the applicant supervises may not serve as a reference. References will not be accepted if written by the applicant. Please familiarize yourself with the requirements and the details of this form before you start. Doing so will enable you to answer all questions as completely as possible. This form must be completed in one sitting. To prevent loss of data should a connection error occur, we suggest writing you answers in a separate program (such as Word) and then cut/paste your answers into this form. When you have finished the form, please click Submit. AttestationI personally composed this Confidential Character Reference Form. All the information contained in it is true, complete, and accurate to the best of my knowledge. I am not related to the applicant and have not been under the applicant’s supervision. We may contact you to verify you are the writer of this form.I agree to use electronic records and signatures.(Required) I agree to use electronic records and signatures. Signature(Required) Completion Date(Required) MM slash DD slash YYYY Name of Applicant(Required) Person Writing Reference(Required) Are you capable of providing an informed and objective description of the Applicant’s professional-level work in environmental, health and safety auditing? CHECKBOX Objective Description(Required) Yes No TEXTBOX Objective Description NODo you know of any reason why this Applicant should not be considered for certification? Do you know of any reason why this Applicant should not be considered for certification?(Required) Yes No Please indicate the nature of your association with the Applicant, and list the time periods during which you have personal knowledge of the Applicant's work experience.Your Role with Applicant(Required) Supervisor / Manager Informed Colleague Professor / Educator Client Other (describe below) From Date:(Required) MM slash DD slash YYYY To Date:(Required) MM slash DD slash YYYY Explain "other" or more info Education(Required)Overall Experience, Professional Ability, and Competence(Required)Skills Related to Environmental, Health and Safety Auditing(Required) Does the Applicant conduct auditing activities in a manner consistent with the BGC Code of Ethics?Does the Applicant conduct auditing activities in a manner consistent with the BGC Code of Ethics(Required) Yes No Professional Integrity / Ethics(Required) Name(Required) First Name Last Name Company Division Address 1(Required) Address 1 Address 2 City US States Zip AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail(Required) If you are certified by the Board for Global EHS Credentialing (BGC), please indicate your certificate number.If you are certified by the Board for Global EHS Credentialing (BGC), please indicate your certificate number. CPEA Candidate Handbook About the CPEA Overview of Steps Reapplicants Eligibility Requirements Exam Exemption Request Eligibility Checklist Documents Needed Character Reference Form Dates, Deadlines, and Fees Exam Overview Exam Preparation Environmental Compliance Health and Safety Management Systems Responsible Care® Sample Questions Exam Scheduling Exam Day Documents and Forms Apply Now Applicants Payments
