Registration Form for the

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Harvey Jack Cross
7 years ago
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1 e Registration Form for the Engineer (FSengineer) Professional (FSP) Expert (FSE)

2 Page 2 of 8 1 Applicant Registration Information Applicant Position Title Birthday Sex Highest education Experiences Years of FS PHOTOS Telephone Telefax MSN: Company & Department Name / Company Address Website Reference 1 (Individual) Position Title/ Company of Reference 1 Phone No. of Reference 1 Reference 2 (Individual) Position Title/ Company of Reference 2 Phone No. of Reference 2 I, the undersigned, hereby confirm the validity of above information. Signature: Date: Page 2 of 8

Title/ Company E-mail of Reference 1 Phone No.

3 Page 3 of 8 2 Eligibility Requirements Eligibility Requirements Engineer (FSengineer) /FS engineer With 2 years experience in the applicable industry at least With Engineering Education diploma With Two references from employed company Have certain ability on speaking English and written English (recommended) Follow a training course and successfully pass the associated exam Professional (FSP) 6 years experience in the applicable industry Education gives credits: Bachelor degree deduct 2 years Masters degree deduct 3 years Ph.D. degree deduct 4 years Two references from employed company Have certain ability on speaking English and written English (recommended Follow a training course and successfully pass the associated exam Expert (FSE) 10 years experience in the applicable industry Education gives credits Bachelor degree deduct 2 years Masters degree deduct 3 years Ph.D. degree deduct 4 years Submits two case studies Competence in communication about. This can be demonstration by publications, dissertations, trainings (as coach), member in FS committees or others Have certain ability on speaking English and written English (recommended) To be a Professional Participant(s) s declaration based on above I am holding a Bachelor I am holding a Master degree I am holding a Ph.D. degree I have two references in related working experience I have two case studies in related working experience to submit I have been as an FSEngineer of TÜV SÜD till now I have been as an FSProfessional of TÜV SÜD till now I have been years experience in the applicable industry till I have successfully passed the exam (date of exam) Competence in communication about (see chapter 3.3) Page 3 of 8

years experience in the applicable industry Education gives credits: Bachelor degree deduct 2 years Masters degree deduct 3 years Ph.D.

4 Page 4 of 8 3 Detailed Informations of applicants 3.1 Relevant Experience (The form can be added if needed) Form 01 Experience 1: Position/Title: Company Name: Location: Start Date Description of duties End Date Supervisor / Manager Name Supervisor / Manager Tel: Total working months: Supervisor / Manager Mail address: Experience 2: Position/Title: Company Name: Location: Start Date: Description of duties: End Date: Supervisor / Manager Name: Supervisor / Manager Tel: Total working months: Supervisor / Manager Mail address: Applicant Name: Total number of years of relevant experience: Signature/Date: Note: I certify that the above information is correct and accurate to the best of my knowledge. I understand that inaccurate information could void my TÜV certification any time in the future. Page 4 of 8

Manager Tel: Total working months: Supervisor / Manager Mail address: Experience 2: Position/Title: Company Name: Location: Start Date: Description of duties: End Date: Supervisor / Manager Name:

5 Page 5 of 8 (The form can be added if needed) Form 02 Experience 3: Position/Title: Company Name: Location: Start Date: Description of duties: End Date: Supervisor / Manager Name: Supervisor / Manager Tel: Total working months: Supervisor / Manager Mail address: Experience 4: Position/Title: Company Name: Location: Start Date: Description of duties: End Date: Supervisor / Manager Name: Supervisor / Manager Tel: Total working months: Supervisor / Manager Mail address: Applicant Name: Signature/Date: Total number of years of relevant experience: Note: I certify that the above information is correct and accurate to the best of my knowledge. I understand that inaccurate information could void my TÜV certification any time in the future. Page 5 of 8

Supervisor / Manager Name: Supervisor / Manager Tel: Total working months: Supervisor / Manager Mail address: Applicant Name: Signature/Date: Total number of years of relevant experience:

6 Page 6 of University Degree (minimum Bachelor's) in relevant field University or College Technical field (major) Degree earned Date Certificate of Diploma Name City Copy attached Country (check box) Applicant Name: Compliance to TÜV SÜD eligibility requirements Signature/Date: Note: I certify that the above information is correct and accurate to the best of my knowledge. I understand that inaccurate information could void my TÜV certification any time in the future. 3.3 Competence in communication for TÜV SÜD FSE Certificate Page 6 of 8

of Diploma Name City Copy attached Country (check box) Applicant Name: Compliance to TÜV SÜD eligibility requirements Signature/Date:

7 Page 7 of Information for TÜV SÜD FSengineer/ FSP / FSE Certificate (please type or write in capital letters) Full Name (first name, second name): (As you would like it to appear on the TÜV Certificate) Company: Mailing Address: address: Phone: Fax: Comments: Page 7 of 8

8 Page 8 of 8 4 Attachments Individual ID CV in English Diploma copies Degree certificate copies Recommend letter Declaration by TÜV SÜD: The above personal information will never to be offered to any other body or person exclude the TÜV SÜD FSCP Governance Board. 5 Our service contact In Germany: Mr Günter Greil Tel/ 电话.: +49/ (0) Fax/ 传真 : +49/ (0) mailto/ 邮件 :guenter.greil@tuev-sued.de Mr Wolfgang Henke Telefon/Phone 电话 : +49 (0) Mobil/Cell 手机 : +49 (0) mailto 邮件 :wolfgang.henke@tuev-sued.de In China: Mr. Zhao Yong / 赵勇先生 Phone/ 电话 : +86/ (0) ext301, Mobile/ 手机 : Fax/ 传真 : +86/ (0) mailto/ 邮件 : yong.zhao@tuv-sud.cn Ms. Li Qian / 李倩女士 Phone/ 电话 : +86/ (0) ext326, Fax/ 传真 : +86/ (0) mailto/ 邮件 : Qian.Li@tuv-sud.cn Page 8 of 8

: +49/ (0) 89-5791 - 1797 Fax/ 传真 : +49/ (0) 89-5791 - 2933 mailto/ 邮件 :guenter.greil@tuev-sued.

PFSE Premier Functional Safety Engineering Safety Instrumented Systems Training Course-TÜV FSEng Certification

PFSE Premier Functional Safety Engineering Safety Instrumented Systems Training Course-TÜV FSEng Certification TÜV Eligibility Form ER04 (This form is computer writable) Training Eligibility Requirements For TÜV Functional Safety Engineer TÜV FSEng Please type or write clearly in block letters. Send completed form