Application

Certification Applied For

Personal details of the applicant

*Name (Full Name) in CAPITAL

Address (with city, state and pincode)

*Email

*Phone Number

Date of Birth

Fill in the name of the trainer and training institute from where you have completed the training. Please ensure that pre-requisite of examination (training) is fullfilled.

Name of institution

Name of trainer

Name of the course

Start date of training

End date of training

Upon completion of the certification requirements, do you wish to have your name, certification level, city of residence and email id published on CCSD’s website?

Yes

Are you suffering from or have limitations caused by any of the situations listed below:

Language of examination is not your native language and hence time to respond in the exam may be more than specified. (For the applicant, whose nationality is different from Indian, provide evidence)

suffer from particular disabilities, for example dyslexia, muscular dystrophy, etc., which adversely affect their ability to complete the examination in the allotted time. For temporary disability like fracture, illness, etc., a candidate shall wait until he recovers and give exam at another scheduled dates. (provide Medical certificate and demonstrate your occupancy in the instrument, chemical and process industry, accordingly CCSD ASIA SDN. BHD shall arrange your examination)

If assistance is needed, please inform CCSD at least 7 days prior to exam date . This request must be submitted together with Medical Documentation as proof.

Declaration of applicant:

a) The applicant commissions CCSD Asia SDN. BHD, Certification Body of Persons, to verify its competence as set forth in the EN ISO/IEC 17024 standard (certification of persons) and issue a certificate of competence for the above certification field.

b) The applicant is aware that his/her personal details (name, first name, academic title, place of birth, date of birth, address including zip/postal code, house number and street, name and address of the client, examination venue, date of examination, certificate number and certificate area) will be stored and processed for the intended purpose.

c) The applicant is aware that CCSD Asia SDN. BHD, Personal Certification, must provide information about the validity of the Functional Safety personal certification on request by interested third parties, while observing data protection regulations.

d) The applicant is not entitled to use CCSD Asia SDN. BHD’s logo. There is no mark for the functional safety certification scheme.

e) The applicant is aware that his/her result and certification will be withheld subject to incomplete application form and non – fulfilment of certification requirements.

Self-disclosure for the certification of Functional Safety

a) The applicant confirms that he/she fulfils the prerequisites in accordance with the scope of certification of the respective scheme applied for, to sit in the examination.

b) The applicant confirms that he/she shall inform to certification body without any delay , of matters that can affect the capability of the certified person to continue to fulfil the certification requirements.

c) The applicant confirms that, after achieving the certification, if the certification of the certified candidate is suspended than the candidate is refrained for further promotion of certification.

d) The applicant confirms that after achieving the certification, in the event of withdrawal, the certified candidate refrains from the use of reference to a certified status.

Applicant shall refer below and ensure that pre-requsite for applied examination is fulfilled.

A copy of documented evidence of completed relevant training and/or a confirmation issued by the employer of work experience must be enclosed with the application wherever applicable.

I accept to perform my duties by accepting the following Code of Ethics of CCSD Asia SDN. BHD – Certification Body

I accept

a) CCSD Asia SDN. BHD Personal Certification requires its certificate holders to conduct themselves professionally, with honesty, impartiality, accurateness, responsibility and independence.

b) CCSD Asia SDN. BHD Personal Certification’s certificate holders should use their knowledge and skills for the enhancement of human welfare.

c) CCSD Asia SDN. BHD Personal Certification’s certificate holder’s performance of their professional duties should include safety, health and welfare of public.

d) CCSD Asia SDN. BHD Personal Certification’s certificate holder should perform their service only in their areas of competence and should avoid conflict of interest

e) CCSD Asia SDN. BHD Personal Certification’s certificate holder should not plagiarize and shall respect the intellectual property of others and do not use them without permission.

f) CCSD Asia SDN. BHD Personal Certification’s certificate holder undertake only those assignments for which they are competent by virtue of certification, training, and experience and, where warranted, seek the assistance of specialists as required to complete of assignments;

g) CCSD Asia SDN. BHD Personal Certification’s certificate holder indicate to the employer or supervisor any decisions that have been overruled by any authority that could result in adverse consequences;

h) CCSD Asia SDN. BHD Personal Certification’s certificate holder should not to use the certification in such a manner as to bring the certification body into disrepute, and not to make any statement regarding the certification which the certification body considers misleading or unauthorized;

i) CCSD Asia SDN. BHD Personal Certification’s certificate holder should discontinue the use of all claims to certification that contain any reference to the certification body or certification upon suspension or withdrawal of certification, and to return any certificates issued by the certification body;

I accept below given Terms and conditions:

I accept

a) If applicant wishes to cancel his/her nomination, he or she must inform us at least seven (7) working days prior to examination date

b) If the applicant fails to attend the examination on the scheduled dates without any prior information, then the cancellation fees is applicable. Applicant can request for new dates and reschedule the examination

c) If applicant fails to successfully complete the examination, he/she can contact CCSD ASIA SDN. BHD for another attempt and to find out the process to enroll.

d) Applicant is to be aware with the CCSD Asia SDN. BHD’s suspension and withdrawal policies mentioned in the product brochures.

e) If a certified candidate is found miss using the certificate, certification mark or logo, he / she is subject to be penalized with suspension of the certificate for three months from the date of identification of misuse. To avoid the misuse of the certification mark or logo, please refer to conditions to use logo or mark by certification body available on website, if applicable.

f) Certification of the candidate will not be released if the pre-requisites are not fulfilled.

g) Any document including, but not limited to any Report or any Certificate, provided by CCSD ASIA SDN. BHD and the copyright contained therein shall be and remain the property of CCSD ASIA SDN. BHD and the Client shall not alter or misrepresent the contents of such documents in any way. The Client shall be entitled to make copies for its internal purposes only.

h) The Certified person shall use the certificate in accordance with the code of ethics mentioned in chapter 9 of this application form. Use of CCSD ASIA SDN. BHD corporate name or any other registered trademarks for advertising purposes is not permitted without CCSD ASIA SDN. BHD prior written consent.

A candidate has right

a) to complaint against any inappropriate practice towards him / her during the complete certification process

b) to have adequate arrangements of examination

c) to have the adequate details of the examination and certification

d) to have the correct status of the certification held by him/her

e) to know the details of any revision in the scope of certification

f) to have the certification mark of the respective scheme, if applicable, subject to terms and condition of its usage

I am aware that incorrect details or misuse of the certificate can result in certificate withdrawal.

I hereby declare that all details given in this document are complete.

I also accept my duties, declarations, self disclosure and all the terms and conditions mentioned in this application form.

Place

Date

Signature