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ISHM Certification Application Form
Summary of Requirements
  • Official College Transcripts from the degree granting institution must be sealed when received by ISHM. ISHM also accepts electronic transcripts.
  • Degrees granted by institutions outside of the United States or Canada must be evaluated for U.S. equivalency by NACES® member organization. http://www.naces.org/
  • Three professional references must be submitted using the References Form. ISHM Certification Reference Form
  • Fees must be paid before ISHM can process your application.
  • Fees are non-refundable.
  • Incomplete applications will not be considered.
  • Invoices are emailed upon receipt of application.
  • Applications are processed in the order they are received. Please allow 7-10 business days to process application.
  • Valid Government Issued Identification” is required for Certification.

Date: (YYYY-MM-DD)

Applying For:

Personal Information

First Name*

Middle Initial: Last/Family Name:

Complete address required for Document Delivery

Home Address: *

City, State, Zip: *

Country:



Contact Information

Cell Phone:

Home Phone:

Work Phone:

Primary Email: *

Secondary Email:

ISHM is environmentally friendly and primarily uses email for day to day business purposes.



Please Check Your Preference

Mailing Address:

Primary Phone Contact:

Secondary Phone Contact:


Certifications Currently Held:
ASHMASPCAIHCHSTCIHCLCSCPEA



Safety Certificate Recognized by ISHM Board

Title and Number:

Issued By:

Date Issued: (YYYY-MM-DD)



Education Information (if required)

Only list institution(s) which granted your degree(s).

School Name:

Address:

City: State: Zip:

Country:

Education: Date of Graduation: (YYYY-MM-DD)

College/University: (Only provide official sealed transcripts from institution granting degree)

Institution:

Address:

City, State, Zip:

Country:

Date of Graduation: (YYYY-MM-DD)

Major, Degree Granted:



Certification

Title and Number:

Issued By:

Date Issued:
(YYYY-MM-DD)

Employment Experience

Please work backward chronologically from your current to previous positions. Use a separate section for each position, including different positions for the same employer. If additional pages are required, include as an attachment.


Current Position



Position Title: Supervisor:

Supervisor’s Phone Number: Email:

Date Employed From: To:

Employer Name:

Address:

City, State, Zip: Country:

Position Type: Total Hours/Week Worked:

Total Hours Spent Performing Safety Duties:

Description of Safety Duties and Responsibilities:



Previous Position



Position Title: Supervisor:

Supervisor’s Phone Number: Email:

Date Employed From: To:

Employer Name:

Address:

City, State, Zip: Country:

Position Type: Total Hours/Week Worked:

Total Hours Spent Performing Safety Duties:

Description of Safety Duties and Responsibilities:

Previous Position

Previous Position

Position Title: Supervisor:

Supervisor’s Phone Number: Email:

Date Employed From: To:

Employer Name:

Address:

City, State, Zip: Country:

Position Type: Total Hours/Week Worked:

Total Hours Spent Performing Safety Duties:

Description of Safety Duties and Responsibilities:

Previous Position

Previous Position

Position Title: Supervisor:

Supervisor’s Phone Number: Email:

Date Employed From: To:

Employer Name:

Address:

City, State, Zip: Country:

Position Type: Total Hours/Week Worked:

Total Hours Spent Performing Safety Duties:

Description of Safety Duties and Responsibilities:

Previous Position

Previous Position

Position Title: Supervisor:

Supervisor’s Phone Number: Email:

Date Employed From: To:

Employer Name:

Address:

City, State, Zip: Country:

Position Type: Total Hours/Week Worked:

Total Hours Spent Performing Safety Duties:

Description of Safety Duties and Responsibilities:

Previous Position

Previous Position

Position Title: Supervisor:

Supervisor’s Phone Number: Email:

Date Employed From: To:

Employer Name:

Address:

City, State, Zip: Country:

Position Type: Total Hours/Week Worked:

Total Hours Spent Performing Safety Duties:

Description of Safety Duties and Responsibilities:

File Attachments

Use these fields to attach required documentation.


Discount Code:

How did you hear about ISHM?:



Personal Certification

I agree to comply with ISHM certification program requirements. (initial)

I agree to supply any information required in assessing my application. (initial)

ISHM may disclose to the general public the status of my certification. (initial)

ISHM may share any, and all, information regarding my certification to appropriate committees. (initial)

When I take a certification exam I agree that I will not disclose any examination content to any third party (initial)

I acknowledge that I have read and agree to abide by the ISHM Code of Professional Conduct. (initial)

Applicants identifying themselves as being disabled as defined by the Americans with Disabilities Act will be provided with the necessary resources and accommodations necessary for them to sit for certification exams. (initial)

I certify that the statements above, together with any attachments, are accurate to the best of my information, knowledge and belief. I also authorize the Institute is authorized to verify all information submitted. I fully understand that any falsification of information in this application or its attachments may be cause for rejection or withdrawal of certification consideration. I further understand that the Institute shall be held harmless for any and all liability with regard to the entire application process, including the institute’s verification of information, and shall also be held harmless for any and all liability should this application be rejected for any reason, including on the basis of information provided hereon or by other party, making me, in the judgment of the institute, ineligible for certification. (initial)

Typing your name and date on the signature line constitutes an electronic signature.

Signature: *

Date: (YYYY-MM-DD)


 

 

 

 

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