EPI – Professional Reference Questionnaire (PRQ) "*" indicates required fields Step 1 of 2 50% Applicant Data THIS QUESTIONNAIRE IS TO BE COMPLETED BY THE REFERENCE WRITER ONLY This reference form is a required document for the application in pursuit of certification through the Board for Global EHS Credentialing (BGC®) as a Environmental Professional In-Training® (EPI®). References from environmental professionals familiar with the applicant's work are immensely valuable in determining whether the applicant is qualified to take the QEP examination for certification. 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. Note: This form must be completed in one sitting. 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. To prevent loss of data should a connection error occur, we suggest writing your answers in a separate program (such as Word) and then cutting/pasting your answers into this form. When you have finished the form, please click Submit. Attestation I personally composed this Professional Reference Questionnaire. 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.* I agree to use electronic records and signatures. Typed Signature*Completion Date MM slash DD slash YYYY Information about the applicantName of Applicant*Person Writing Reference*The applicant is known to me in the environmental profession as:The applicant is known to me in the environmental profession as* My Employee My Colleague Other (explain below) Role From Date:* MM slash DD slash YYYY Role From To:* MM slash DD slash YYYY Explain "other" or more infoThe applicant's environmental area of expertise is known to me as:The applicant's environmental area of expertise is known to me as* Air Water Waste Policy and Management Science and Health Other (explain below) 2. Explain "other" or more infoI consider the applicant's education and experience to be:I consider the applicant's education and experience to be* Outstanding Good Average Fair Poor Paragraph Text: education and Experience*I consider the applicant's professional ability and competence to be:I consider the applicant's professional ability and competence to be* Outstanding Good Average Fair Poor Paragraph Text: professional ability and competence*I believe the applicant's appreciation for professional ethical conduct is:I believe the applicant's appreciation for professional ethical conduct is* Outstanding Good Average Fair Poor Paragraph Text: Professional ethical conduct*I believe the applicant is qualified for certification as an Environmental Professional In-Training:I believe the applicant is qualified for certification as a Qualified Environmental Professional.* Yes No (explain below) Text Box: Explain "no" abovePlease provide any other information you believe would be helpful with our evaluation of the applicant. Reference DataName* First Last Company / Organization*Division*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Telephone*Email* Are you a certified QEP?Are you a certified QEP?* Yes No EPI Candidate Handbook About the EPI Overview of Steps Reapplicants Eligibility Requirements Documents Needed Application and Exam Fees Exam Overview Exam Preparation Exam Scheduling Exam Day Documents and Forms Apply Now Applicants Payments
