OIP CREDENTIALING APPLICATION
INSTRUCTIONS
Each
application must meet the following requirements
before it will be processed:
1.
APPLICATION COMPLETENESS -- Application
must be filled out completely and signed by the
applicant.
2.
PHOTO -- APPLICANT'S PHOTO MUST BE
INCLUDED as verification.
3.
FEES -- All application fees must be
included.
4.
REGISTRATION(s) REQUESTED
Infrastructure Preparedness
Management/Coordination programs
____Registered
Incident Preparedness Associate (RIPA) -
$100
____Certified
Infrastructure Preparedness Specialist (CIPS)
- $895 Workshop fee, Exam Required.
____Certified
Incident Management Train-the Trainer (CIMT)
- $895 Workshop fee, Exam Required.
____Certified
Emergency and Security Professional (CESP)
- $895 Workshop fee, Exam Required.
____Certified
Safety, Environmental, and Emergency Management
Specialist (CSEM)
- $895 Workshop fee, Exam Required.
SELECT
DISCIPLINE SPECIFIC SKILLS, KNOWLEDGE AND
ABILITIES Ц
APPLICATION
AND ANNUAL RENEWAL FEE
____Transportation
____Communications
____Information
Systems ____Cargo
Security
____Medical
Services
____Threat Management
____Risk
Assessment
____Environmental Management
____Community
Planning
____Finance/Administration
____Restoration
and Remediation ____Logistics
Management
____Emergency
Response ____Public
Safety
____Science/Technical Support
____Resource Management
____Public
Information
____Law Enforcement
____First
Responder
____other: _________________________
The sworn
resume that you submit must clearly provide
evidence that you are qualified by education,
training and work experience to be registered
for any of the above categories selected.
5. GENERAL
INFORMATION
(Print
or type clearly)
Dr./Mr./Ms/Military Rank.
________
Name: (Last
name, first name, middle)
_______________________________________________________
Position Title:
____________________________________________________________________________
Employer:
_______________________________________________________________________________
Level of
Security
Clearance__________________________________________________________________
Preferred
Mailing Address:
_________________________________________________________нннн_________
City:
______________________________ State: ________
Zip:_________________
Phone:
____________________________ Fax::
_____________________________
Email:
_______________________________________________________________
PAYMENT
METHOD
CHECK #
_______________ AMOUNT: ________________
CREDIT CARD:
Э
AMEX Э MC
Э VISA
#_____________________________________________________
EXPIRATION
DATE: _________ CREDITCARD
HOLDER SIGNATURE:
_______________________________
COMPLETE
and PROVIDE INFORMATION and SIGN on REVERSE SIDE
OF THIS FORM
and
Mail this application and payment to: OIP,
P.O. Box 2099, Glenview, IL 60025-6099
FOR
USE BY APPOINTING OFFICER ONLY:
Date
Received: ________________________
Payment: _______________________
Degrees/Major: ________________________
Workshop: ______________________
Years
Experience: _____________________
References Included: ______________
Certifications:
_________________________ File Complete:
____________________
Comments:
__________________________________________________________________________
____________________________________________________________________________________
SEND
MISSING FORM FOR:
__________________________________________________________
Signature
and Title of Appointing
Officer___________________________________________________
6. EDUCATION
On a separate sheet of paper list in
chronological order the name, city and state of
each educational institution beyond high school
attended. For each degree claimed, you must
provide a photocopy of your diploma or a
photocopy transcript of grades.
List additional specialized
training courses, etc. on separate sheet of
paper.
7. EXPERIENCE (standard resume acceptable)
On a separate sheet of paper list the following
information: For each period of time that the
applicant claims experience in the
Infrastructure Preparedness field, provide the
employer's name, address, dates of employment,
name of individual to whom you reported, your
title (if any), and a narrative description of
your specific responsibilities.
8. ETHICS CERTIFICATION AND ATTESTATION:
I hereby attest to, and certify that, the
following statements are true, correct and
complete to the best of my knowledge, and I
further agree to fulfill the obligations set
forth as follows:
1. __Y __N I have never been the subject
of any professional or occupational
credentialing, license, certification or
registration ethics or other disciplinary
matter(s) or proceeding(s).
2. __Y __N I have never been found guilty
of any felony criminal offenses.
3. __Y __N I understand that any
intentional or unintentional failure to
provide true and complete responses to this
application may result in sanctions by the
OIP Board of Directors or Ethics Committee.
If you have answered "NO" to any statement(s)
above, please provide a written explanation.
9. CERTIFICATION OF ACCURACY, AGREEMENT
AND RELEASE AUTHORIZATION:
I understand and agree that OIP has the
right to contact any person, government
agency or entity, or organization to review
or confirm any information provided in this
application. I further agree to authorize
the release of any information requested by
OIP with respect to the review of this
application. I understand that all material
becomes the property of OIP upon receipt and
that neither originals nor photocopies will
be returned to me. I further understand
that if I am granted registration and/or
certification by the OIP and practice, I do
so at my own risk. I hereby release the
NREP/OIP from any and all liability and
claims that may arise from any and all
activity in private practice or otherwise.
I understand and agree that OIP registration
and/or certification and recertification
depends upon my fulfillment of all required
criteria, and obligations including
compliance with the NREP/OIP Code of
Ethics. I further agree to fully inform the
OIP, in timely manner, if I become the
subject of any ethics, disciplinary,
criminal, or lesser offenses, complaints or
charges. In the event that my registration
and/or certification is suspended or
revoked, I agree to comply with all
directives or orders of the OIP Board of
Directors, including the return of all OIP
credentialing documents. I agree to comply
with such directives and orders in a timely
manner and at my own expense.
___________________________________
_________________
Applicant's
Signature
Date
