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Please complete this form and mail, email or fax it, along with all supporting documents referred to in this form to:
Mail: (ISC)2 Programs Attn: Endorsement Assistance 33920 U.S. Highway 19N, Suite 205 Palm Harbor, FL 34684 USA
Use this form only if you are unable to secure a qualified (ISC)2 certified professional to endorse you. Endorsement by (ISC)2 may take up to 6 weeks. Please consider finding a qualified member to endorse you by using any of the following resources: (ISC)2 Member Directory, ISSA chapters, LinkedIn, Facebook, and Twitter. You must provide the following supporting documents along with this form: l Completed Job/Position Worksheets l Proof of employment for all work experience claims l Proof of waiver claim (certifications) l Resume/CV with description of job duties as related to domains CISSP Requirements The Candidate must have a minimum of five years of direct full-time security work experience in two or more of these 10 domains of the (ISC) CISSP CBK:
l l l l l
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management
l l l l l
Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security
(ISC) CBK Domain Name Changes Coming Soon: We are making some changes to the CBK domain names for the CISSP, SSCP and CISSP-ISSEP. Please see the list below for the effective dates. NOTE: These changes do not affect experience requirements for any (ISC) certifications or concentrations. Please refer to the appropriate CIB for details: -January 1st, 2012 - CISSP -February 1st, 2012 - SSCP -March 1st, 2012 - CISSP-ISSEP
CANDIDATE INFORMATION
Last Name/Surname: First Name/Given: Examination #:
EDUCATION/CERTIFICATION WAIVER
I am claiming a waiver for: Bachelor Degree University Name: Masters Degree University Name:
If certain circumstances apply and with appropriate documentation, candidates are eligible to waive a maximum of one year of professional experience for education or for holding an additional credential on the (ISC) approved list. See www.isc2.org/credential_waiver/ for details.
Date:
Date:
Approved Certificate (A list of (ISC) approved certificates can be fournd at http://www.isc2.org/credential_waiver/default.aspx.) Name:
Proof of degree/certification is attached.
Date:
07/06/2010 Page 1
JOB/POSITION WORKSHEET #1
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead. If you need more than 5 worksheets, you will find additional worksheets at the end of this form.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor Email: To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes:
JOB/POSITION WORKSHEET #2
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead. If you need more than 5 worksheets, you will find additional worksheets at the end of this form.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor Email: To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes:
JOB/POSITION WORKSHEET #3
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead. If you need more than 5 worksheets, you will find additional worksheets at the end of this form.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor Email: To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes:
JOB/POSITION WORKSHEET #4
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead. If you need more than 5 worksheets, you will find additional worksheets at the end of this form.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor Email: To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes:
JOB/POSITION WORKSHEET #5
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead. If you need more than 5 worksheets, you will find additional worksheets at the end of this form.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor Email: To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes:
Domain Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governanceand Risk Management Legal, Regulations, Investigations, and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security I claim a 12 month waiver for one of the following: (Place '12' in the box if you are claiming a waiver.) College Degree Authorized Certification
SUPPORTING DOCUMENTATION
I have included all of the following documentation to support my work experience claim:
Resume/CV with description of job duties as related to domains Copy of Certificate/Diploma/letter from University or other to support my waiver claim (if applicable) Proof of employment for each Job/Postion form Contact Information for supervisor/reference fo each position listed (name, phone, and email.).
07/06/2010
Page 7
I understand and agree that this request is contrary to the (ISC)2 Privacy Policy and am requesting (ISC)2 to waive the Privacy Policy concerning my records for the sole purpose of seeking endorsement assistance for me. Upon completion of the endorsement process, my records will continue to be subject to the (ISC)2 Privacy Policy. In exchange for (ISC)2's assistance in providing an appropriate (ISC)2 certificate holder to review, and possibly, endorse, my records for certification, I agree to hold (ISC)2 and the selected (ISC)2 certificate holder reviewing my records harmless for any action or inaction that might arise from reviewing my records and rendering a professional opinion, whether positive or negative, regarding my qualifications for certification by (ISC)2.
Name:
Examination #:
Date:
APPLICANT AGREEMENT
I have read the (ISC)2 Code of Ethics and hereby confirm that I will comply with it in the future. All information provided by me in this application is true to the best of my knowledge. (ISC)2 may, at its sole discretion, make inquiry of individuals and organizations directly or indirectly referenced in any part of this application to verify the accuracy and completeness of the information I have provided. I further agree to cooperate in any such investigation by (ISC)2 regarding the information I have provided, including my criminal history. I understand that providing any information that is fraudulent, or failing to completely or accurately disclose facts known to me, or my failure to cooperate in any inquiry by (ISC)2 into the information I have provided, will result in the refusal of (ISC)2 to issue the credential to me, and being forever barred from holding the credential. Any action arising out of the application, the examination, or the certification must be brought in the Circuit Court of Suffolk County, Massachusetts, USA, and shall be governed by the laws of the State of Massachusetts.
I HAVE READ AND UNDERSTAND THESE STATEMENTS AND INTEND TO BE LEGALLY BOUND BY THEM. Signature:
(Print and sign or Digital Signature)
Date:
CISSP
CAP
SSCP
CSSLP
Position/Job Title:
Certification Number:
I give this endorsement freely and without any conflict of interest, am acting in my professional capacity recognizing that material misrepresentations or omissions may make me subject to discipline, and recognizing that the integrity of the certification depends upon the quality of my endorsement.
Date
Endorser's Signature
Copyright 2009 (ISC)2, Inc. All rights reserved. All contents of this form constitute the property of (ISC)2, Inc. and may not be copied, reproduced or distributed without prior written permission. All marks are the property of the International Information Systems Security Certification Consortium, Inc.
07/06/2010
Page 8
JOB/POSITION WORKSHEET # 6
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor Email: To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes:
JOB/POSITION WORKSHEET #7
Please complete the Job/Position Worksheet below for each position you are claiming as relevant work experience. We strongly recommend that you include proof of employment for each worksheet you complete. Proof should include, when applicable, a letter from HR or supervisor, signed and on company letterhead.
Employer Name: Date of Employment (mm/yy) Supervisor or HR Contact: From: Name: Phone: Job/Position Title Analyst Architect Consultant Cryptanalyst Cryptographer Cryptologist Designer Director Engineer Investigator Instructor Leader Manager Officer Professor Programmer Representative Salesperson Supervisor email To:
Other
Specify:
Domain Indentification
This job/position demonstrates experience in the following domains:
Access Control Application Development Security Business Continuity and Disaster Recovery Planning Cryptography Information Security Governance and Risk Management Legal, Regulations, Investigations and Compliance Operations Security Physical (Environmental) Security Security Architecture and Design Telecommunications and Network Security Comments/Notes: