CPSA Application "*" indicates required fields Review the CPEA/CPSA Application Preparation document and complete the CPSA Eligibility Checklist before starting to make sure you have the information and materials needed to complete Stage 1 and Stage 2 of the application process. This checklist is for self-evaluation purposes only; do not submit it. There are four (4) stages to the application process: Stage 1: The Application, which consists of profile information, education (see Path 1, 2, or 3 of the Eligibility Checklist) and attestation to the BGC Code of Ethics. The applicant will request official transcripts or an evaluation report and send out at least two (2) Character Reference Forms (CRF). You may also include the Test Accommodations online form and/or Exam Exemptions online form. If the exemption is accepted and approved, a link will be emailed for payment. The Exam Exemption Fee payment is non-refundable. Stage 2: The Application Fee Payment (non-refundable). Stage 3: The Fillable PDF Forms: Statement of Audit Experience, Statement of Formal Training, and Statement of Work Experience which will be emailed to you after we receive the application and application fee. You must complete and upload the forms within two (2) years from the date of application submission and payment. A self-evaluation form, CPSA Eligibility Checklist, is included among the files for your use in tracking your own progress. (Not updated or reviewed by staff.) Stage 4: The Exam. All parts of the application must be completed and approved by BGC prior to taking the exam. You will not receive your grades on individual parts until all have been completed. The average of the exam parts must be at least 70% for a passing score. Please Note: The credential is not awarded until all parts of the application process have been completed, reviewed, approved, and you have passed the exam. Directions This is the online form to apply for the Certified Process Safety Auditor (CPSA) credential. Be Aware: This application must be completed in one session. We recommend that you: Review the CPSA Candidate Handbook pages on this site for requirements and processes. Complete a CPSA Eligibility Checklist to see if requirements are met. Complete the application, answering all questions as completely as possible. When you have finished the application, please click Submit. Continue to the Payment page to complete payment for the application. The application fee is non-refundable. BGC will email the link to a SharePoint folder which will contain the remaining documentation necessary to complete your application. The folder is not a management system but a temporary location for you to upload completed forms and supporting documents after: Application and Payments are received. APPLICATION FORM Answer all questions as completely as possible. When you have finished the application, please click Submit. Thank you.PLEASE CHOOSE YOUR GENERAL WORK EXPERIENCE PATHWAY* Path 1: At least 7 years' experience and hold a Bachelor's degree Path 2: At least 15 years' experience with a secondary school diploma Path 3: At least 10 years' experience and hold an Associate's degree Process Safety-Verifiable Experience (select at least two) Gained during the last 10 years in at least two of the areas described below: (Use your Control or Command key to select multiple options.)Safety Experience Checkbox 1*Implementation of Process Safety ProgramsProcess Hazard AnalysisManagement of ChangePre start-up Safety ReviewsMechanical IntegrityProcess Safety InformationProduct Stewardship, Transportation or Distribution of Hazardous ProductsRequirements of Process Safety Laws, Regulations, and Related DocumentsProcess Safety Management Systems and StandardsProcess Safety Audting Procedure, Processes, and Auditing TechniquesName* First Middle Last Please indicate any previously-used last / surnames.Previous Name *Please advise BGC if your legal name has changed since graduating from a college or university. Documentation of name changes (legal decision, marriage certificate, for example) must be sent to BGC via email at applications@GoBGC.org or postal mail: BGC, ATTN: CPEA/CPSA, 6005 W. St. Joseph Hwy Ste 300, Lansing, MI 48917 USA. AddressesPlease provide both your work and home addresses. Check your preference for mailing purposes and internet roster listing. Please provide both your work and home addresses. Check your preference for mailing purposes and internet roster listing.Use Work AddressUse Home AddressCompany Name Division Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business CountryAfghanistanAlbaniaAlgeriaAmerican 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 Business PhoneBusiness Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home CountryAfghanistanAlbaniaAlgeriaAmerican 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 Personal / Mobile PhonePersonal Email Do you hold another BGC credential? (If yes, please use the Control or Command key to select multiple certifications to the right.)Do you hold another BGC credential?* No Yes Another Credential picker*NoneCIHQEPEPICPPSCPEACPSA Have you previously applied for, but not been issued, another BGC credential? (If yes, please use the Control or Command key to select multiple certifications to the right.)Have you previously applied for, but not been issued, another BGC credential?* No Yes Applied before picker*N/ACIHQEPEPICPPSCPEACPSA An official transcript or secure e-transcript sent directly from each U.S. college or university attended is required. Official transcripts may also be sent by you in an envelope sealed with the registrar's seal. See the CPSA Candidate Handbook pages on this site for requirements about equivalency reports needed for international degrees awarded outside of the U.S./Canada. Degree 1* Major 1* School 1* Date Awarded 1* MM slash DD slash YYYY Please list any double major for this degree.double major input Do you have any non-degree education to list?Do you have any non-degree education to list?* Yes No Non-degree Coursework Non-degree Coursework NonDegreeSchool1 Do you have a second degree to list?* Yes No Degree 2 Major 2 School 2 Date Awarded 2 MM slash DD slash YYYY Please list any double major for this degree.double major input 2 Do you have a third degree to list?* Yes No Degree 3 Major 3 School 3 Date Awarded 3 MM slash DD slash YYYY Please list any double major for this degree.double major 3 input Per the CPSA Candidate Handbook pages on this site, I understand the following: Official transcripts must be submitted for each degree. An official transcript is one sent directly to BGC by your college or university through mail or as secure e-transcripts. Alternatively, you may submit official transcripts if they are in a sealed envelope with the registrar's stamp across the seal. International applicants must order a Document-by-document Evaluation Report from a NACES or AICE member organization for each degree. Applicants who hold a Bachelor's, Master's, or doctoral degree from an accredited college or university in the U.S. or Canada may not be required to submit an evaluation report. If your transcripts have a name different from the name under which you are applying, please submit documentation of the name change to applications@GoBGC.org. (e.g., marriage certificate, divorce decree, etc.) When a degree includes credits that were transferred from another college or university, official transcripts for those course credits must be sent upon request. Email address for transcripts: applications@GoBGC.org. Physical address for transcripts: BGC, ATTN: CPEA/CPSA, 6005 W. St. Joseph Hwy Ste 300, Lansing, MI 48917 USA. Transcripts to BGC Select* Yes No I understand that it is my responsibility to submit the nonrefundable payment for this application and to complete the forms that BGC will send to me. I further understand that it is my responsibility to direct my references to complete the Character Reference Form.PRQ To References*YesNoBy typing my name below, I certify that the information I have provided is, to the best of my knowledge, accurate and truthful. I understand that any falsification in this application for Certified Professional Safety Auditor credential will be grounds for rejection or for later revocation of any certificate issued. I understand that I am subject to the terms and conditions set out for applicants in the CPSA Candidate Handbook pages on this site in effect at the time of application. I also recognize my obligation not to reveal the contents of the CPSA examinations. I agree to adhere, to the best of my ability, to the Code of Ethics and be governed by the Ethics Case Procedures as published on the GoBGC.org website. If I am certified, I understand that I must pay annually such amount as BGC shall decide as a part of the CPSA certification maintenance requirement.Typed Signature* Date MM slash DD slash YYYY BGC does not discriminate among applicants as to age, sex, race, religion, national origin, disability, or marital status.I am submitting a Test Accommodation Request Form for a disability covered by the Americans with Disabilities Act as amended or other applicable laws.Accommodations*NoYes CPSA Candidate Handbook About the CPSA Overview of Steps Reapplicants Eligibility Requirements Eligibility Checklist Exam Exemption Request Documents Needed Character Reference Form Dates, Deadlines, and Fees Exam Overview Exam Preparation Sample Questions Exam Scheduling Exam Day Documents and Forms Apply Now Applicants Payments
