CPPS – Professional Reference Questionnaire (PRQ) Step 1 of 5 - Application Data 20% THIS QUESTIONNAIRE IS TO BE COMPLETED BY THE REFERENCE WRITER ONLY Directions: This is the online form to submit a professional reference for an individual applying for the Certified Professional Product Steward® (CPPS®) credential. 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 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.(Required) I agree to use electronic records and signatures. Typed Signature(Required) 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 Product Stewardship? Yes No Please explain No answer above, if applicable.Do you know of any reason why this Applicant should not be considered for certification? 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 Colleague (non-supervisory) Professor Client Other (describe below) Role From Date:(Required) MM slash DD slash YYYY Role To Date:(Required) MM slash DD slash YYYY Explain Other selection above or add additional information: Work History 1 The practice of Product Stewardship encompasses the health, safety, regulatory compliance, legal, sustainability, and environmental aspects of chemical raw materials, intermediates, and/or industrial, commercial, and consumer products throughout their life cycle and across the value chain. Please describe the Applicant's product stewardship activities for each position held during the time periods for which you have direct personal knowledge.Position 1 Title(Required) Position 1 From Date(Required) MM slash DD slash YYYY Position 1 To Date(Required) MM slash DD slash YYYY Date professional-level practice began for this job, if different from the employment start date:Date pro level began 1(Required) MM slash DD slash YYYY Average number of hours per week devoted to professional-level product stewardship practice:(Required) What percentage of total work time is devoted to the practice of professional-level product stewardship?(Required) Describe specific work functions and activities, addressing the criteria listed below:Depth of Work(Required)Level of interaction(Required)Responsibilty for Work Outcome(Required)Do you have another position to report for this applicant? Yes No Work History 2 Position 2 Title(Required) Position 2 From Date(Required) MM slash DD slash YYYY Position 2 To Date(Required) MM slash DD slash YYYY Date professional-level practice began for this job, if different from the employment start dateDate professional-level practice began for this job, if different from the employment start date(Required) MM slash DD slash YYYY Average number of hours per week devoted to professional-level product stewardship practice:(Required) What percentage of total work time is devoted to the practice of professional-level product stewardship?(Required) Describe specific work functions and activities, addressing the criteria listed below:Work History 2 Depth of workWork History 2 Level of interactionWork History 2 Responsibilty for Work Outcome Describe the Applicant's ability to perform with independent technical responsibility and identify any significant technical deficiencies.(Required)Does the Applicant conduct product stewardship activities in a manner consistent with the BGC Code of Ethics?Does the Applicant conduct product stewardship activities in a manner consistent with the BGC? Yes No Name(Required) First Last Company/ Organization Division Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Phone(Required)Email(Required) If you are certified by the Board for Global EHS Credentialing (BGC), please indicate your certificate numberIf you are certified by the Board for Global EHS Credentialing (BGC), please indicate your certificate number ALL references and supporting materials must be submitted no later than December 15 immediately preceding the spring examinations, and no later than June 1 immediately preceding the fall examinations. CPPS Candidate Handbook About the CPPS Overview of Steps Reapplicants Eligibility Requirements Documents Needed CPPS PRQ Form Dates, Deadlines, and Fees Exam Overview Exam Preparation Exam Scheduling Exam Day Documents and Forms Apply Now Applicants Payments
