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CERTIFICATION JUNE/DECEMBER EXAMS

EXAM
Retake ASQ Member Nonmember
CPGP $219 $269 $419

The Global Voice of Quality TM APPLICATION CSQE


CQA
$219
$219
$269
$269
$419
$419
CQE $219 $269 $419
CQIA $129 $189 $339
1. ASQ MEMBERSHIP NUMBER CCT $129 $189 $339
CQPA $129 $189 $339
If you are not an ASQ member, leave blank CSSGB $159 $209 $359

Prices above are in U.S. dollars.


2. NAME/ADDRESS INFORMATION
 Mr.    Ms.    Mrs.    Dr. (Print clearly or type) EXAMINATION DATES
Your application must be postmarked, faxed, or emailed by
  First Name Middle Initial Last Name the application deadline. Applications sent after the deadline
will automatically incur an additional, nonrefundable, $50
  Home Address Apt./Ste.
late registration fee. Applications received after the late
application deadline will automatically be processed for the
next examination date.
  City, State/Prov., Zip/Postal Code Country
Examination Application Late Application
  Home Area Code and Telephone Number Dates Deadline Fee Deadline
Dec. 6, 2014 Oct. 17, 2014 Oct. 22, 2014
  Employer Name Your Title June 6, 2015 April 17, 2015 April 22, 2015
Dec. 5, 2015 Oct. 16, 2015 Oct. 21, 2015
  Employer Address Apt./Ste.
EXAM FEE TOTALS
You may pay by check, money order, bank draft, Visa,
  City, State/Prov., Zip/Postal Code Country
MasterCard, or American Express. Tuition vouchers and
purchase orders are not accepted.
  Bus. Area Code and Telephone Number Fax Number
Your application will be returned unprocessed if payment
is not enclosed. $50.00 of your fee is an application fee
  Email Address and is not refundable.
If you are interested in becoming a member, include
3. FEE Check the applicable box below. payment and the membership application with your
certification fee.
March/October____________
MARCH/OCTOBER EXAMS June/December____________
Retake ASQ Member Nonmember
Total____________
CQI $129 $189 $339 Method of payment:
CQT $129 $189 $339
CRE $219 $269 $419 Check or money order (U.S. dollars drawn on a U.S. bank)
CMQ/OE $289 $339 $489 Make check payable to ASQ.
CHA $219 $269 $419 Visa MasterCard American Express (Check one)
CBA $219 $269 $419
CSSBB* $259 $309 $459 Cardholder’s Name (please print)
CSSYB** $129 $189 $339
Card Number Exp. Date
Prices above are in U.S. dollars.
* Your Six Sigma Black Belt application will be on hold Cardholder’s Signature
until your affidavit(s) is (are) received at ASQ.
Cardholder’s Address
Completed affidavit(s) must be received at ASQ
within one week of receiving your application.
Applicant’s Signature Date
If not, your application will be canceled and a partial
refund (less application fee) will be returned to you. Fees subject to change without notice.
If the payment amount submitted is incorrect or a price
** First administration will be March 7, 2015 for the
increase occurs, we will bill you accordingly or charge your
CSSYB exam.
credit card the appropriate amount.
EXAMINATION DATES To register online, visit www.asq.org and click Certification.
Your application must be postmarked, faxed, or emailed Provide Promo Code CERTAPP.
by the application deadline. Applications sent after
the deadline will automatically incur an additional, 4. EXAMINATION SITE
nonrefundable, $50 late registration fee. Applications Please list your ASQ section number for testing location.
received after the late application deadline will
automatically be processed for the next examination date. Section Number

Examination Application Late Application
International applicants, please print the name of the major city
Dates Deadline Fee Deadline and country where you would prefer to take the examination on
Oct. 4, 2014 Aug. 15, 2014 Aug. 20, 2014 the lines below.
Mar. 7, 2015 Jan. 16, 2015 Jan. 21, 2015
City____________________________________________________
Oct. 3, 2015 Aug. 14, 2015 Aug. 19, 2015
Country_________________________________________________
Fees are subject to change without notice. For the most up-to-date information, visit www.asq.org.
5. EDUCATION You must attach a résumé or provide your work experience
below; employment dates must be by month/year.
Complete the entire section below showing the highest completed
Job Title__________________ From______ To ________(Mo/Yr)
educational degree or diploma you have received. Credit is not
Employer_________________ Supervisor____________________
issued for nondegree education or for partially completed degree
programs. Address________________________________________________
Job Title__________________ From______ To ________(Mo/Yr)
International applicants must provide documentation to verify Employer_________________ Supervisor____________________
educational equivalency.
Address________________________________________________
Degree or Diploma_____________________ Year______________ Job Title__________________ From______ To ________(Mo/Yr)
Name of Institution _______________________________________ Employer_________________ Supervisor____________________
Location of Institution______________________________________ Address________________________________________________
Type of degree or diploma (check one)    technical school  7. COMPLIANCE WITH RULES
  associate    bachelor’s    master’s    doctorate Please read the ASQ Code of Ethics below. Compliance with
the Code of Ethics is mandatory for all certified individuals,
6. WORK EXPERIENCE whether or not they are members of ASQ.
If you do not meet all of the necessary qualifications, you will
“I have read, I understand, and I agree to comply with the
not be allowed to take this exam.
ASQ Code of Ethics. I agree not to discuss or release in any form
CQIA and CQPA require TWO years of work experience or an the contents of the examination. I affirm that all information
associate degree or TWO years of equivalent higher education. contained in this application is correct.”
CQI requires TWO years of work experience. If you do not have Signature____________________________________________
a high school diploma or GED, you must have THREE additional
Please print your name_________________________________
years’ work ­experience.
Date_________________________________________________
CQT requires FOUR years of higher education and/or work
experience.
CRE, CQA, CQE, and CSQE require EIGHT years of higher ASQ CODE OF ETHICS
education and/or work experience including THREE years in FUNDAMENTAL PRINCIPLES
a decision-making position.
ASQ requires its members and certification holders to
CBA and CHA require FIVE years of work experience including conduct themselves ethically by:
ONE year in a decision-making position.
I. Being honest and impartial in serving the public, their
CMQ/OE requires 10 years of higher education and/or work
employers, customers, and clients.
experience including FIVE years in a d ­ ecision-making position.
CSSBB requires TWO completed projects with signed affidavits II. Striving to increase the competence and prestige of the
or ONE project with signed affidavit and THREE years of work quality profession, and
experience. No education waivers are given. III. Using their knowledge and skill for the enhancement of
CCT requires FIVE years of higher education and/or work experience. human welfare.
CPGP requires FIVE years of on-the-job experience including THREE
Members and certification holders are required to observe
years in a decision-making position. No education waivers are given.
the tenets set forth below:
CSSGB requires THREE years of work experience.
CSSYB requires ONE year of work experience. No education RELATIONS WITH THE PUBLIC
waivers are given. Article 1— Hold paramount the safety, health, and welfare
All work experience must relate to one or more areas of the of the public in the performance of their professional
body of knowledge of that specific certification. duties.
“DECISION MAKING” is defined as having the authority to define, RELATIONS WITH EMPLOYERS, CUSTOMERS,
execute, or control projects/processes and being responsible for
AND CLIENTS
the outcome.
Article 2— Perform services only in their areas of competence.
If you have been certified by ASQ in any of the areas below, please
provide your certificate number in lieu of work experience. If you are Article 3— Continue their professional development throughout
applying for the manager exam, you’ll need to include additional their careers and provide opportunities for the
work experience. professional and ethical development of others.
CQA CQE Manager CRE CSQE Article 4— Act in a professional manner in dealings with ASQ
staff and each employer, customer, or client.
Certificate Number__________________ Date_____________
Article 5— Act as faithful agents or trustees, and avoid
The following does not apply for CQI, CSSBB, CPGP, CSSGB, conflicts of i­nterest and the appearance of conflicts
or CSSYB. of interest.
If you have completed a degree, diploma, or certificate program
beyond high school, you may waive some of the required RELATIONS WITH PEERS
experience as follows:
Article 6— Build their professional reputation on the merit of their
Certificate/diploma from a technical— services and not compete unfairly with others.
One year, CCT two years or trade school
Article 7— Ensure that credit for the work of others is given to
Associate degree (college or technical institute) those to whom it is due.
Two years, CBA, CHA one year
Bachelor’s degree
Four years, CCT two years, CQT, CHA, CBA three years
Master’s/doctoral degree
Five years, CCT two years, CQT three years, CBA,
CHA four years If you have special needs that we can address, call
ASQ Certification Offerings at 800-248-1946 or
DID YOU … 414-272-8575.
• Complete both sides of the application?
• Include payment? Return This Application To:
• Attach your résumé or provide your work experience ASQ
with employment dates by month/year? P.O. Box 3066
• Sign your application? Milwaukee, WI 53201-3066
• Include your CSSBB affidavit(s)? (Affidavits can be found Fax 414-272-1734
at asq.org/cert.)
Item B1529 The Global Voice of Quality TM