CPEA / CPSA Attestation of Recertification Activities All CPEAs/CPSAs must document that they have met requirements for ongoing certification by reporting activities that contributed to their professional competence over their last certification cycle. Directions: Please fill out and submit this form below, including the total number of recertification activity (CPD) hours completed for the period from January 1, 2018 – December 31, 2022 ONLY IF the Initial Cycle date we have given you is 12/31/22. For the 2018-2022 cycle, the expected hours for the time period above is 60, including ethics. Please note: Former IIA members have been assigned an Initial Cycle end date that may be 12/31/20 (or 2021, 2022, 2023, 2024). After that time, your new cycle will be a full five years. Your Initial Cycle end date is available on the CPEA roster or the CPSA roster. That information was also included in emails and postal mail sent the first week of December, 2020. BGC operates on five-year cycles and does not require annual reporting. At the end of your initial (and subsequent full five-year cycle), you will, at that time, complete this Attestation Form for the full (or partial) cycle. DO NOT SUBMIT this form if you are not at the end of your cycle. Ethics training must be reported separately from other activities but will count toward the minimum requirement of 20 hours per year: at least two hours, but not more than six hours per cycle. Any training you have completed in the previous five years from your cycle end date (Initial or Full) will count towards your total. For example: hours gained from 1/1/2018 to 12/31/2022 is valid for those attesting with a cycle end date of 12/31/22. It is your responsibility to keep official records supporting recertification activities (CPD) and provide them to BGC Certification Staff if your certification is randomly selected for an audit.First Name(Required)Last / Surname(Required)RegistryIDCertification(s)(Required)CPEACPSACPEA and CPSAEmail(Required) Email Confirm Email Address(Required) Address Address2 City State / Province 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 Please indicate below for which specialites you are submitting this form. (on PCs, hold the Control key to select more than one item)SpecialitySelection(Required)EMS 14000+Management SystemResponsible CareEnvironmental ComplianceHealth and SafetyProcess SafetyNumber of hours for recertification (not including ethics) HoursNonEthics(Required)Number of hours for recertification in Ethics(Minimum of 2 and maximum of 6 hours)HoursEthics(Required)I attest that the statements on this form are true and correct to the best of my knowledge. During the period covered by this worksheet, I have not been made aware of any charges against me of unethical practice of EHS auditing. I have never been convicted of a criminal offense (a) for which one could potentially be sentenced to more than one year in prison or death or (b) involving dishonesty or a false statement. I agree to adhere, to the best of my ability, to the BEAC Code of Ethics/BGC Code of Ethics(Required) I attest that the statements on this form are true and correct to the best of my knowledge. During the period covered by this worksheet, I have not been made aware of any charges against me of unethical practice of EHS auditing. I have never been convicted of a criminal offense (a) for which one could potentially be sentenced to more than one year in prison or death or (b) involving dishonesty or a false statement. I agree to adhere, to the best of my ability, to the BEAC Code of Ethics/BGC Code of Ethics CPSA CM Handbook About CPSA Recertification Overview of Steps Annual Requirements Ethics Current Contact Information Annual Fees Staying Current Recertifying by Exam Recertifying by Points CM Point Categories 1-Active Practice 2-Professional Service 3-Publications 4-Continuing Education 5-Teaching or Presenting 7-Other Approved Activities Dates, Deadlines, and Fees Dates and Deadlines Reporting Calendar Hardship Options Cycle Extension Leave of Absence Giving up Certification Voluntary Surrender Retired Status Involuntary Decertification Reactivating Certification Volunteer Opportunities Documents and Forms Public Roster Practitioner Payments