CERTIFICATION JUNE/DECEMBER EXAMS

CPGP ................................. Retake................. 12,045/-

EXAM ASQ Member................................................
Nonmember.................................................
14,795/-
23,045/-

APPLICATION CSQE ................................. Retake.................

ASQ Member................................................
12,045/-
14,795/-
Nonmember................................................. 23,045/-
1. ASQ MEMBERSHIP N U MB E R CQA .................................. Retake................. 12,045/-
If you are not an ASQ member, leave blank ASQ Member............................................... 14,795/-
Nonmember................................................. 23,045/-
2. N A M E / A D D R E S S INFORMATION CQE ................................. Retake................ 12,045/-
Mr. Ms. Mrs. Dr. (Print clearly or type) ASQ Member............................................... 14,795/-
Nonmember................................................. 23,045/-
CQIA ................................. Retake................. 7,095/-
ASQ Member.............................................. 10,395/-
First Name Middle Initial Last Name Nonmember................................................ 18,645/-
CCT ................................. Retake................ 7,095/-
Home Address Apt./Ste. ASQ Member.............................................. 10,395/-
Nonmember................................................ 18,645/-
City, State/Prov., Zip/Postal Code Country CQPA ................................. Retake................ 7,095/-
ASQ Member............................................. 10,395/-
Home Area Code and Telephone Number Nonmember............................................... 18,645/-
CSSGB ................................. Retake............... 8,745/-
Employer Name Your Title ASQ Member.............................................. 11,495/-
Nonmember............................................... 19,745/-
Employer Address Apt./Ste.
EXAMINATION DATES
City, State/Prov., Zip/Postal Code Country Your application must be postmarked, faxed, or emailed by the extended
application deadline. Applications sent after the extended deadline will
automatically incur an additional, nonrefundable, ` 2,750/- late
Bus. Area Code and Telephone Number Fax Number
registration fee. Applications received after the late application deadline
will automatically be processed for the next examination date.
Email Address
Examination Extended application Late application
Dates Deadline Fee Deadline
3. FEE Dec. 1, 2012 Oct. 12, 2012 Oct. 17, 2012
Check the applicable box below. June 1, 2013 April 12, 2013 April 17, 2013
Dec. 7, 2013 Oct. 18, 2013 Oct. 23, 2013
MARCH/OCTOBER EXAMS
CQI ................................. Retake................. 7,095/-
ASQ Member............................................... 10,395/- EXAM FEE TOTALS
Nonmember................................................. 18,645/- You may pay by cheque/dd favouring American Society for Quality
CQT ................................. Retake................. 7,095/- India Pvt. Ltd.
ASQ Member............................................... 10,395/- Your application will be returned unprocessed if payment is not enclosed.
Nonmember................................................. 18,645/- `2,750/- of your fee is an application fee and is not refundable.
CRE ................................. Retake................. 12,045/- If you are interested in becoming a member, include payment and
ASQ Member................................................ 14,795/- the membership application with your certification fee.
Nonmember................................................. 23,045/-
March/October
CMQ/OE................................. Retake................. 15,895/-
ASQ Member............................................... 18,645/- June/December
Nonmember................................................. 26,895/- Total
CHA ................................. Retake................ 12,045/-
ASQ Member............................................... 14,795/- Method of Payment:
Nonmember................................................ 23,045/- Cheque or DD Payable to American Society for Quality India Pvt. Ltd.
CBA ................................. Retake................ 12,045/- Fees subject to change without notice.
ASQ Member............................................... 14,795/- If the payment amount submitted is incorrect or a price increase occurs, we will
Nonmember................................................ 23,045/- bill you accordingly or charge your credit card the appropriate amount.
CSSBB* ................................. Retake................. 14,245/-
To register online, visit www.asq.org.in and click Certification.
ASQ Member............................................... 16,995/-
Nonmember................................................. 25,245/-
* Your Six Sigma Black Belt application will be on hold until your affidavit(s)
4. EXAMINATION SITE
is (are) received at ASQ.
Completed affidavit(s) must be received at ASQ within one week
Please list your ASQ section number for testing location.
of receiving your application. Section Number 2 5 2 9 -
If not, your application will be canceled and a partial refund (less
application fee) will be returned to you. International applicants, please print the name of the major city and country
where you would prefer to take the examination on the lines below.
EXAMINATION DATE City
Your application must be postmarked, faxed, or emailed by the extended
application deadline. Applications sent after the extended deadline will Country ______________________________________________________________________
automatically incur an additional, nonrefundable, `2,750/- late
registration fee. Applications received after the late application deadline
will automatically be processed for the next examination date.
Examination Extended application Late application INDIA CENTRE CODE
Dates Deadline Fee Deadline
MUMBAI – 00 PUNE – 02 CHENNAI – 03 DELHI – 04
Oct. 6, 2012 Aug. 17, 2012 Aug. 22, 2012
March 2, 2013 Jan. 11, 2013 Jan. 16, 2013 BANGALORE – 05 HYDERABAD – 06 KOLKATA – 07 AHMEDABAD–08
Oct. 5, 2013 Aug. 6, 2013 Aug. 21, 2013

Please complete both sides of this application

 5. EDUCATION 7. COMPLANCE WITH RULES
Please read the ASQ Code of Ethics below. Compliance with the
Complete the entire section below showing the highest completed
educational degree or diploma you have received. Credit is not Code of Ethics is mandatory for all certified individuals, whether or not
issued for nondegree education or for partially completed degree they are members of ASQ.
programs. “I have read, I understand, and I agree to comply with the ASQ
International applicants must provide documentation to Code of Ethics. I agree not to discuss or release in any form the contents
verify educational equivalency. of the examination. I affirm that all information contained in this
application is correct.”
Degree or Diploma Year

Name of Institution Signature

Location of Institution
Please print your name
Is this a (circle one) technical school diploma or an associate,
Date / /
bachelor’s, master’s, or doctorate degree?

6. WORK EXPRIENCE
If you do not meet all of the necessary qualifications, you will not be ASQ CODE OF ETHICS
allowed to take this exam.
FUNDAMENTAL PRINCIPLES
CQIA and CQPA require TWO years of work experience or
ASQ requires its members and certification holders to conduct
an associate degree or TWO years of equivalent higher
themselves ethically by:
education.
I. Being honest and impartial in serving the public, their employers,
CQI requires TWO years of work experience. If you do not have a high
school diploma or GED, you must have THREE additional years’ work customers, and clients.
experience. II. Striving to increase the competence and prestige of the quality
CQT requires FOUR years of higher education and/or work experience. profession, and
CRE, CQA, CQE, and CSQE require EIGHT years of higher III. Using their knowledge and skill for the enhancement of
education and/or work experience including THREE years in a human welfare.
decision-making position.
Members and certification holders are required to observe the
CBA and C H A require FIVE years of work experience including ONE tenets set forth below:
year in a decision-making position.
CMQ/OE requires 10 years of higher education and/or work RELATIONS WITH THE PUBLIC
experience including FIVE years in a decision-making position.
Article 1— Hold paramount the safety, health, and welfare of the
CSSBB requires TWO completed projects with signed affidavits or ONE
public in the performance of their professional duties.
project with signed affidavit and THREE years of work experience. No
education waivers are given.
CCT requires FIVE years of higher education and/or work experience.
RELATIONS WITH EMPLOYERS,
CPGP requires FIVE years of on-the-job experience including THREE years CUSTOMERS AND CLIENTS
in a decision-making position. No education waivers are given. Article 2— Perform services only in their areas of competence.
CSSGB requires THREE years of work experience. Article 3— Continue their professional development throughout
All work experience must relate to one or more areas of the body of their careers and provide opportunities for the
knowledge of that specific certification. professional and ethical development of others.
Article 4— Act in a professional manner in dealings with ASQ staff and
“DECISION-MAKING” is defined as having the authority to define,
execute, or control projects/processes and being responsible for the each employer, customers, or client.
outcome. Article 5— Act as faithful agents or trustees, and avoid conflicts of
If you have been certified by ASQ in any of the areas below, please provide interest and the appearance of conflicts of interest.
your certificate number in lieu of work experience. If you are applying for
the manager exam, you’ll need to include additional work experience. RELATIONS WITH PEERS
CQA CQE Manager CRE CSQE Article 6— Build their professional reputation on the merit of their services
and not compete unfairly with others.
Certificate Number
Article 7— Ensure that credit for the work of others is given to those to
Date / / whom it is due.
The following does not apply for CQI, CSSBB, CPGP, or CSSGB.
If you have completed a degree, diploma, or certificate program beyond
high school, you may waive some of the required experience as follows:
Certificate/diploma from a technical or 1 year,
DID You …
trade school CCT 2 years
• Complete both sides of the application?
• Include payment?
Associate degree (college or technical 2 years,
• attach your résumé or provide your work
institute) CBA, CHA 1 year
Bachelor’s degree 4 years, experience with employment dates by
CCT 2 years, month/year?
CQT, CHA, CBA 3 years • Sign your application?

Master’s/doctoral degree 5 years, • Include your CSSBB affidavit(s) ? (affidavits

CCT 2 years, can be found at

CQT 3 years, asq.org/certification/index.aspx)
CBA, CHA 4 years
You must attach a résumé or provide your work experience below;
employment dates must be by month/year.
Job Title From (Mo/Yr) To (Mo/Yr)

Employer

Address If you have special needs that we can

Supervisor
Address, call ASQ Certification offerings
at 800-248-1946 or 414-272-8575.
Job Title From (Mo/Yr) To (Mo/Yr)

Employer
Return this application to:
Address
American Society for Quality India Pvt. Ltd.
Supervisor 325, 3rd Floor, DLF Tower B,
Jasola District centre, New Delhi - 110025
Job Title From (Mo/Yr) To (Mo/Yr) T.: +91 11 46783399 F: +91 11 40793573
E: asqindia@asq.org
Employer You may also join online at
http://asq.org.in and www.asq.org
Address

Supervisor Item B1529