ISHM Certification Reference Form

The reference form should be completely filled out. Those providing the reference should have personal knowledge of the applicants Safety and Health work activities. When finished click on the submit button at the bottom of the page. References may be mailed directly to ISHM (at the above address) or to the applicant for forwarding.

The applicant named below is seeking a professional certification by meeting academic and experience requirements, passing an examination, and receiving satisfactory references. Important information you provide as to the applicant’s qualifications will assist in making decisions for examination and certification. Your honesty and assistance in this matter is appreciated.

Applicant Seeking Reference

Name:* Position/Title:

Person Providing Applicant's Reference

Name:* Position/Title:

Company: *

Phone Number: *

Email Address: *


Address Continued:

City: State/Province: Zip:

Reference Questions

How long have you had personal knowledge of the applicant’s safety and health management qualifications?

From: To:

What is or was the nature of your work relationship with the applicant?:

If other, describe:

Please describe the applicant’s safety and health related activities and responsibilities and performance of the applicant during the time you were familiar with his/her professional activities:

In addition to safety related duties what other work related duties or responsibilities does applicant have?:

Are you aware of any technical deficiencies or ethical lapses of the candidate?:

If yes, describe:

Please use this space to provide any additional comments deemed relevant:

Reference Certification

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.

Signature:* Date:*


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