If you are not an ASQ member, complete the attached membership application and return it with this form

CERTIFIED QUALITY MANAGER APPLICATION

FOR OFFICE USE ONLY ASQ MEMBERSHIP NUMBER

Work Experience Decision making Education

Date Initials

If you are not an ASQ member, leave blank

Released

NAME/ADDRESS INFORMATION
Job Description/Resume

Mr.

Ms.

Dr.

Mrs.

Is this a new address?

EXAMINATION DATE

First Name Address City, State, Zip Code Area Code and Telephone Number Employer Name Employer Address City, State, Zip Code Area Code and Telephone Number E-mail Address

Middle Initial

Last Name Apt./Ste. Country

Your application must be postmarked or faxed by the application deadline or it will be automatically processed with the applications for the next examination date. Exam Date October 20, 2001 March 2, 2002 October 19, 2002 Application Deadline August 24, 2001 January 11, 2002 August 23, 2002

Your Title Apt./Ste. Country Fax Number

EXAMINATION SITE

Please list your ASQ section number for testing location.

Section Number

International applicants, please print the name of the major city and country where you would prefer to take the examination on the lines below.
City Country

FEE

Check the applicable box below. If you are interested in becoming a member, include payment for membership options with your certification fee. You may pay by check, money order, bank draft, VISA, MasterCard, or American Express. Tuition vouchers and purchase orders not accepted. Your application will be returned unprocessed if payment is not enclosed. $50.00 of your fee is an application fee and is not refundable. 1. ASQ Member 2. Nonmember 3. Exam Retake (DO NOT USE IF YOU: Tested more than two years ago, did not take your last exam, or are recertifying.) $235.00 U.S. $340.00 U.S.

Complete the entire section below showing the highest completed educational degree or diploma you have received. Credit is not issued for non-degree education or for partially completed degree programs. International applicants must provide documentation to verify educational equivalency.
Degree or Diploma Year

EDUCATION

$185.00 U.S.

Method of payment: Check or money order (U.S. dollars drawn on a U.S. bank)
Make check payable to ASQ.

VISA

MasterCard

American Express (Check one)

Name and Location of Institution

Cardholders Name Card Number Cardholders Signature Cardholders Address Applicants Signature

(please print) Exp. Date

Is this a (circle one) technical school diploma, associates degree, bachelors, masters, or Ph.D?

Date

Fees subject to change without notice. If the payment amount submitted is incorrect or a price increase occurs, we will bill you accordingly or charge your credit card the appropriate amount.

If you have special needs that we can address, call ASQs Certification Department at 800-248-1946 or 414-272-8575.
Please complete both sides of this application.

WORK EXPERIENCE

IF YOU DO NOT MEET ALL OF THE NECESSARY QUALIFICATIONS, YOU WILL NOT BE ALLOWED TO SIT FOR THIS EXAM.

Certification as a Quality Manager requires that you have at least ten years of higher education and/or work experience in one or more of the areas of the Certified Quality Manager Body of Knowledge (see p. 8), including a minimum of five years in a decision-making position. Decision-making is defined as the authority to define, execute, or control projects/processes and to be responsible for the outcome. This may or may not include management or supervisory positions. 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 trade school Associate degree (college or technical institute) Bachelors degree Masters/doctoral degree You may claim only one of these waivers. 1 year 2 years 4 years 5 years

Please check the appropriate box below and attach the required supporting documentation. You must check one of these three boxes. I am a member of ASQ, an international affiliate society, or another society that is a member of the American Association of Engineering Societies or the Accreditation Board for Engineering and Technology. I am registered as a Professional Engineer. A photocopy of my certificate of registration is attached. I have obtained the signatures (below) of two persons who are ASQ members or members of an international affiliate society or of another recognized professional society, attesting that they have personal knowledge of my professional activities as a practitioner of the Quality Sciences and that I am capable of meeting the requirements of ASQ membership and the ASQ Code of Ethics.
Signature Society Date / /

PROOF OF PROFESSIONALISM

You must attach a resume or provide your work experience below; employment dates must be by month/year.
Job Title Employer Address Supervisor From (Mo/Yr) To (Mo/Yr)

Signature Society Date / /

From (Mo/Yr) To (Mo/Yr)

COMPLIANCE WITH RULES

Please read the ASQ Code of Ethics on p. 7 of this brochure. Compliance with the Code of Ethics is mandatory for all certified individuals, whether or not they are members of ASQ.

Job Title Employer Address

I have read, and I understand, the rules of certification contained in this brochure, and I agree to comply with them and with the ASQ Code of Ethics. I agree not to discuss or release in any form the examination contents. I affirm that all the information contained in this application is correct.
Signature

Supervisor

Please print your name Date / /

Job Title Employer Address Supervisor

From (Mo/Yr)

To (Mo/Yr)

DID YOU - Complete both sides of the application - Include payment - Attach your resume or provide your work experience with employment dates by month/year - Sign your application

Return This Application To: ASQ P .O. Box 3066 Milwaukee, WI 53201-3066 Fax 414-272-1734

Priority code: CTAACT1