Eligibility Form

Premier Consulting Services
PFSE PFSE
Course-TÜV FSEng Cert
Premier Functional Safety Engineering
Safety Instrumented Systems
Course-TÜV FSEng Certification www.premier-fs.com
TÜV Eligibility Form ER04

(This form is computer writable)
PFSE
Training Course-TÜV FSEng Certification
Eligibility Requirements
For TÜV Functional Safety Engineer
TÜV FSEng
Please type or write clearly in block letters.
Send completed form ER04 with all attached documents to:

(scanned and attached to an e-mail is preferred method)
Note: “This form is only

required after the participant
Invensys-Premier Consulting Services passes the exam. We
Attn: Mr. Robin McCrea-Steele normally attach this form to
the e-mail sent to each
student with the result of the
e-mail: robin.mccreasteele@ips.invensys.com exam. The form then should
be completed (form is
writable), signed and sent to
Phone: +1-949-885-0774 Irvine, California, together
with copies of the university
Fax: +1-949-753-9101 diploma, certificate or
company letter, as
approriate. This package is
best sent by scanning and
Applicant Name: ……………………………………… attaching to an e-mail to
Premier headquarters in
California. Fax or mail is
Company: ……………………………………………… also acceptable.
Alternatively, the student
may fill out ahead of time
Date: …………………………… and give to the instructor
during the course.”
1
PFSE PFSE
PFSE Training Course
TÜV Eligibility Requirements Form ER04

(According to TÜV Functional Safety Program)
A minimum of 3 to 5 yrs University degree “or” equivalent

experience in the field of “AND” engineer level responsibilities status
functional safety as certified by employer letter.
Name: ………………………………………………………………
1- Functional Safety relevant experience
Position / Title Company Name Location
Start date: Description of duties:
End date:
Total # months:
Supervisor / Manager Name: ……………………………….
End date:
Total # months:
2
PFSE PFSE
Functional Safety relevant experience (continued)
End date:
Total # months:
End date:
Total # months:
Applicant Name: Total Number of years of relevant Functional

Safety experience:
(minimum 3 years) ……………………….
Note: I certify that the above information is correct and
Signature: accurate to the best of my knowledge.
I understand that inaccurate information could void my TÜV
certification any time in the future.
3
PFSE PFSE
2- University degree (minimum Bachelor’s) in relevant field “or” equivalent

engineer level responsibilities status as certified by employer letter.
Name: …………………………………………………………………….
University
Technical field Certificate or
or Degree earned Date
(major) Diploma
College
Name:
Copy attached
(check box)
City:

Country:
“or”
Date Company
Company Technical field Title / Responsibility
Certification
Name:
Signed letter
attached *
City: (check box)

Country:
* Letter shall be on Company letterhead and signed by a manager level official.
Applicant Name: Compliance to TÜV eligibility requirements.
Note: I certify that the above information is correct and

Signature: accurate to the best of my knowledge.
I understand that inaccurate information could void my TÜV
certification any time in the future.
4
PFSE PFSE
Information for TÜV Certificate

(How you would like your name to be shown on your TÜV Certificate)
Please type or write in block letters
Full name: ……………………………………………

(as you would like it to appear on the TÜV Certificate)
Mailing Address: ………………………………….

(Indicate if Company address)
………………………………….
………………………………….
………………………………….
e-mail address: ………………………………….

Phone: ………………………………….
Fax: ………………………………….
Comments:……………………………………………………………..
…………………………………………………………………………...
……………………………………………………………………………

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Premier Consulting Services

TÜV Eligibility Form ER04

Please type or write clearly in block letters.

Send completed form ER04 with all attached documents to:

Note: “This form is only

PFSE Training Course

TÜV Eligibility Requirements Form ER04

 A minimum of 3 to 5 yrs  University degree “or” equivalent

1- Functional Safety relevant experience

Position / Title Company Name Location

Start date: Description of duties:

Position / Title Company Name Location

Start date: Description of duties:

TÜV Eligibility Requirements Form ER04

Functional Safety relevant experience (continued)

Position / Title Company Name Location

Start date: Description of duties:

Position / Title Company Name Location

Start date: Description of duties:

Applicant Name: Total Number of years of relevant Functional

TÜV Eligibility Requirements Form ER04

2- University degree (minimum Bachelor’s) in relevant field “or” equivalent

* Letter shall be on Company letterhead and signed by a manager level official.

Applicant Name:  Compliance to TÜV eligibility requirements.

Note: I certify that the above information is correct and

TÜV Eligibility Requirements Form ER04

Information for TÜV Certificate

Please type or write in block letters

Full name: ……………………………………………

Mailing Address: ………………………………….

e-mail address: ………………………………….

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A minimum of 3 to 5 yrs University degree “or” equivalent

Applicant Name: Compliance to TÜV eligibility requirements.