QEP Recertification Form Step 1 of 4 - Recertificant Data 25% Directions: Please answer all questions to complete this application. When you have finished the form please click Submit. BGC randomly selects 5% of the recertifying QEPs each year for an audit. BGC will send an audit notice to you if you have been randomly selected. 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. Requirements: Group I: minimum of 10 points Group II: minimum of 20 points Group III (Ethics): minimum of 1 point (max of 3) (Beginning in 2023) Total of 50 points for recertification Full recertification guidelines and audit documentation information are available at GoBGC.org/practitioners_QEP. You may also email: Certifications@GoBGC.org. For assistance with the breakdown of PDH categories, consult the Summary of QEP Recertification Guidelines document. Since the date of your initial application for QEP certification, have you been criminally convicted of a misdemeanor or felony, had a professional license or certification revoked, or had a certification granted by a non-governmental organization revoked?Since the date of your initial application for QEP certification, have you been criminally convicted of a misdemeanor or felony, had a professional license or certification revoked, or had a certification granted by a non-governmental organization revoked?(Required) No Yes If you answered "yes", please contact certifications@GoBGC.org after submitting this form. Answering "yes" does not automatically prevent recertification as a QEP, but the specific circumstances involved will be thoroughly reviewed by BGC.Address (please use your mailing address)Name(Required) First Name Last/Surname Address(Required) Address 1 Address 2 City State/Province 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 Business Phone(Required)Mobile Telephone(Required)Email(Required) Email Confirm Email Group I - Contributions and Services to the Profession and CommunityPDH credits are per event, per year, and require 2 hours of time investment for every credit. The total number of PDHs required for recertification is 50 which may be accrued over the entire five years, in any fashion, provided that a minimum of 10 PDHs are accrued in Group I and 20 PDHs are accrued in Group II. QEPs who have allowed their certification to lapse may reactivate. Please visit GoBGC.org/practitioners_QEP. Professional Development Hours (PDHs) Claimed (minimum of 10 needed in this group) Directions: Use the TAB key to move between fields. Holding Officea. (1)Holding Office(e.g. Committee Chair, Vice-Chair, Secretary, Board Trustee, Regional Coordinator)Committee Membera. (2)Committee MemberMeeting/Conference Chair or Vice-Chaira. (3)Meeting/Conference Chair or Vice-ChairSession Chair or Vice-Chaira. (4)Session Chair or Vice-ChairMeeting Author or Co-Authora. (5)Meeting Author or Co-Author(of technical paper, extended abstract, poster session paper, or panel session member)Adjunct Teachinga. (6)Adjunct Teaching(when not QEP's primary occupation, maximum of 20 points per year)Teaching Certificate Review Coursea. (7)Teaching Certificate Review Course(e.g. CIH, CPEA, QEP, CHMM, 2 points per course for a maximum of 6 points per year)EPI Mentora. (8)EPI Mentor(1 PHD per EPI per quarter with a maximum of 6 points per year)QEP Test Item Contributora. (9)QEP Test Item Contributor(1/2 PDS per question accepted by chair of Exam Committee for a maximum PDH accumulation per year of 5)Exam Proctor or Panel Membera. (10)Professional certification exam (environmentally-related) proctor/panel memberPro Bono Community/Career involvementb.Pro Bono Community/Career involvement(e.g., pro bono involvement that is environmentally-related: environmental public agency advisory board, citizens groundwater advisory group, county toxic chemicals advisory panel)Pro Bono Environmental Presentationsc.Pro Bono Environmental Presentations(environmentally-related to schools, public, and/or civic audiences)Publication in Peer-reviewed Journald.Publication in Peer-reviewed Journal(maximum of five publications per five years)Author/Editor of Published Booke.Author/Editor of published environmentally-related bookAuthor of Chapter(s) of Published Bookf.Author (not prime) of one or more chapters of a published environmentally-related bookYou must have at least 10 points in Group I. Total Group 1 PDH Credits Claimed: {Group1Total:119} (minimum of 10 needed in this group)Total Group 1 PDH Credits Claimed Group II - Continuing Professional Development Professional Development Hours (PDHs) Claimed (minimum of 20 needed in this Group) Directions: Use the TAB key to move between fields. Membership in Society/Organizationa.Membership in national or international environmentally-related professional societies or organizationsMembership in Local/Regional Chapterb.Membership in local or regional chapter of environmentally-related professional societies or organizationsActive Employment in Environmental Professionc.Active Employment in Environmental ProfessionAttendance at Annual/Semiannual Meetings of Organizationsd.Attendance at annual or semi-annual meetings, seminars, or special conferences of environmentally-related organizationsGraduate Education Coursese,Participation of graduate education courses(per quarter/semester evidenced by transcripts, must be an accredited school.)Environmentally-related Short Coursesf.Environmentally-related short courses(greater than or equal to 1 day in length, 3 points per class with a maximum of 6 points per year.)Environmentally-related Seminarsg.Environmentally-related seminars(less than 1 day in length, 1 point per session.)Attendance at Employer's Seminar or Training Programi.Attendance at employer's seminar or training program(1 point per event with a maximum of 3 events per year for a total of 15 points per 5-year cycle)New (Environmental) CertificationNew (Environmental) certification in an area related to the environmental field(May only be used if the new certification occurred subsequent to attainment of the QEP certification and during the five years previous to the current recertification.)You must have at least 20 points in Group II. Total Group II PDH Credits Claimed: {Group1Total:120} (minimum of 20 needed in this Group)Total Group II PDH Credits Claimed Group III - EthicsMinimum 2 hours (= 1 PDH point) to a maximum of 3 PDH points every 5-year cycle. Requirement begins 1/1/2023Total Group III PDH Ethics Credits ClaimedTotal Group III PDH Ethics Credits ClaimedYou must have at least 50 points overall to recertify. Total PDH Credits Claimed: {Number: Group III Ethics:106} (minimum of 50 needed overall)Total PDH Credits ClaimedAgreementI certify that I have veen actively engaged in environmental and/or related sciences for at least three of the previous five years and that I have accrued the minimum number of Professional Development Hours (PDHs) required for recertification by the BGC Recertification Program, as shown on this PDH worksheet. I further affirm that if selected for an audit, I will submit evidence of such for audit no later the thirty days following my five-year certification anniversary date. I further affirm that I have abided by, and will continue to abide by, the ethical principles set forth by BGC, I will: Recognize the limitations of one's professional ability and provide services only when qualified. The certificant/candidate is responsible for determining the limits of his/her own professional abilities based on education, knowledge, skills, practice, experience, and other relevant considerations; Continually seek to maintain and/or enhance their professional capabilities; Comply with laws, regulations, policies, and ethical standards governing professional practice; Follow appropriate health and safety procedures, in the course of performing professional duties, to protect clients, employers, employees, and the public from conditions where injury and damage are reasonably foreseeable; Maintain high standards of integrity and professional conduct. I agree to use electronic records and signatures.(Required) I agree to use electronic records and signatures. Signature: I certify(Required)Date/Time(Required) MM slash DD slash YYYY QEP CM Handbook About QEP 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 Retirement Status Involuntary Decertification Reactivating Certification Volunteer Opportunities Documents and Forms Public Roster Practitioner Payments