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D.

QUALIFICATION REFERENCE
(Pleasemakeasmanycopiesofthisformasnecessarytoprovidethe
appropriatenumberofQualificationReferencesneeded)

APPLICANT:CompleteItemsD.1,D.2,andD.3thenforwardthisformtothepersonyouhavelistedin
ItemD.3.AskthispersontocompletetheremainderoftheformandreturnitdirectlytoNACE
InternationalInstitute.

Qualificationreferencesmaybesubmittedbythefollowing,whichhaveexpertiseinthecorrosionfield
andcanverifytherequiredfield/instrumentationexperience:

Registeredorcharteredengineers
Presentand/orprevioussupervisor(s)oftheapplicant
P.M.ofthereferredProject
NACEInternationalInstitutecertificateholders(ForCIPLevel3applicants,oneQualification
ReferencemustholdaNACEInstituteCertificateatthelevelbeingappliedfor.)

D.1 ApplicantsFullName:

D.1A NACEMemberID#:

D.2 Certificationcategoryappliedfor:

D.3 Name,title,companyname,address,andphonenumberofpersonwhoisfamiliarwiththe
workexperienceoftheapplicant:

Phone:

REFERENCE:TheapplicantisapplyingforprofessionalrecognitionbyNACEInternationalInstitute.
Applicantsforcertificationmustmeetspecificrequirements;pleaseseethelistoftheserequirements
onthefollowingpage.Evaluationofanapplicantsqualificationsalsodependsonassessmentof
professionalexperiencebyreferences.ItisrequestedthatyoucompleteItemsD.4throughD.13onthis
formandreturnitdirectlytoNACEInstitute.

D.4 IholdNACEInstituteCertificationasa:
(Leavethissectionblankifthissectionisnotapplicable)

Certified No.

IamaRegisteredEngineer(orequivalent)

State/Province: Branch: No:


D.5 Ihaveknowntheapplicantforyears.Whatis/wasthenatureoftheassociation?

CurrentSupervisor PreviousSupervisor

CurrentClient PreviousClient

CurrentCoworker PreviousCoworker

CurrentProfessor/Instructor PreviousProfessor/Instructor

Other(Pleasespecify)

D.6 Frompersonalknowledge,myassessmentoftheapplicantscharacterandpersonalreputation
isthatitis:

Excellent Average Belowaverage

D.7 Frompersonalknowledge,Iknowthattheapplicanthasbeenengagedinthefieldofcoatings
relatedfieldworkforyears.(Definedascoatingsrelatedfieldworkinanindustrialsettingwhere
protectivecoatingsareinspected).

D.8 Basedonthispersonalknowledge,Iknowthatthequalityoftheapplicantsworkinthefieldof
Coatingsis

Excellent Average Belowaverage

D.9 Theapplicantisproficientinthefollowingphasesofcoatingsinspection:

D.10 Wouldyouemploy,orrecommendtheemploymentof,theapplicantforemploymentinthe
phaseofcoatinginspectionyouhavedescribedinItemD.9?

Yes No

NACEInternationalInstituteCertificationProgram

D.11 PleasedescribeINYOUROWNWORDSanymajorprojects/activitiesinwhichtheapplicanthas
beeninvolvedinthefieldofcoatingsinspectionwork.Describeonlythosewhereyouhad
personalknowledgeoftheapplicantswork.Pleaseindicatethedegreeofresponsibility
exercisedbytheapplicant,thecomplexityoftheproject/activity,thename/sandtype/softhe
project/s,thedegreeofknowledge/skillrequired,etc.
(Youcanattachaseparatesheetifyouwish,orifyouneedmorespace).

**THED.11SECTIONMUSTBECOMPLETEDBEFORETHE
APPLICATIONCANBESUBMITTEDFORREVIEW**

D.12 Anyadditionalremarksyouwouldliketoaddconcerningthisapplicant:

D.13 MysignaturebelowindicatesthatIhavepersonalknowledgeandexpertiseinthecorrosion
fielduponwhichtoevaluatetheapplicantsprofessionalcapabilities.

Signature: Date:

PrintedName:

Thecompletedformcanbereturnviaemailorregularmail:

NACEInternationalInstitute
CertificationDepartment
15835ParkTenPlace
Houston,TX77084USA

Email:cipapplications@nace.org

NACEInternationalInstituteCertificationProgram