PFSE

Premier Functional Safety Engineering

Safety Instrumented Systems
Course-TV FSEng Certification

Premier Consulting Services

PFSE
Course-TV FSEng Cert

www.premier-fs.com

TV Eligibility Form ER04

(This form is computer writable)

PFSE
Premier Functional Safety Engineering
Safety Instrumented Systems
Training Course-TV FSEng Certification

Eligibility Requirements
For TV Functional Safety Engineer
TV 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)

Invensys-Premier Consulting Services

Attn: Mr. Robin McCrea-Steele
robin.mccreasteele@invensys.com
e-mail: robin.mccreasteele@ips.invensys.com

Phone: +1-949-885-0774
Fax:
+1-949-753-9101

Applicant Name:
Company:
Date:

Note: This form is only

required after the participant
passes the exam. We
normally attach this form to
the e-mail sent to each
student with the result of the
exam. The form then should
be completed (form is
writable), signed and sent to
Irvine, California, together
with copies of the university
diploma, certificate or
company letter, as
approriate. This package is
best sent by scanning and
attaching to an e-mail to
Premier headquarters in
California. Fax or mail is
also acceptable.
Alternatively, the student
may fill out ahead of time
and give to the instructor
during the course.

PFSE
Premier Functional Safety Engineering
Safety Instrumented Systems
Course-TV FSEng Certification

Premier Consulting Services

PFSE
Course-TV FSEng Cert

www.premier-fs.com

PFSE

Training Course

TV Eligibility Requirements Form ER04

(According to TV Functional Safety Program)

A minimum of 3 to 5 yrs
experience in the field of
functional safety

AND

University degree or equivalent

engineer level responsibilities status
as certified by employer letter.

Name:
1- Functional Safety relevant experience
Position / Title

Company Name

Start date:

Description of duties:

Location

End date:

Total # months:

Supervisor / Manager Name: .

Position / Title

Company Name

Start date:

Description of duties:

Location

End date:

Total # months:

Supervisor / Manager Name: .

PFSE
Premier Functional Safety Engineering
Safety Instrumented Systems
Course-TV FSEng Certification

Premier Consulting Services

PFSE
Course-TV FSEng Cert

www.premier-fs.com

TV Eligibility Requirements Form ER04

Functional Safety relevant experience (continued)
Position / Title

Company Name

Start date:

Description of duties:

Location

End date:

Total # months:

Supervisor / Manager Name: .

Position / Title

Company Name

Start date:

Description of duties:

Location

End date:

Total # months:

Applicant Name:

Supervisor / Manager Name: .

Total Number of years of relevant Functional

Safety experience:
(minimum 3 years)

Signature:

Note: I certify that the above information is correct and

accurate to the best of my knowledge.
I understand that inaccurate information could void my TV
certification any time in the future.

PFSE
Premier Functional Safety Engineering
Safety Instrumented Systems
Course-TV FSEng Certification

Premier Consulting Services

PFSE
Course-TV FSEng Cert

www.premier-fs.com

TV Eligibility Requirements Form ER04

2- University degree (minimum Bachelors) in relevant field or equivalent
engineer level responsibilities status as certified by employer letter.
Name: .
University
or
College

Technical field
(major)

Degree earned

Date

Certificate or
Diploma

Name:
Copy attached
(check box)

City:

Country:

or
Company

Technical field

Title / Responsibility

Date

Company
Certification

Name:

City:

Signed letter
attached *
(check box)

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

Applicant Name:

Signature:

Compliance to TV eligibility requirements.

Note: I certify that the above information is correct and
accurate to the best of my knowledge.
I understand that inaccurate information could void my TV
certification any time in the future.

Premier Consulting Services

PFSE
Course-TV FSEng Cert

PFSE
Premier Functional Safety Engineering
Safety Instrumented Systems
Course-TV FSEng Certification

www.premier-fs.com

TV Eligibility Requirements Form ER04

Information for TV Certificate
(How you would like your name to be shown on your TV Certificate)

Please type or write in block letters

Full name:

(as you would like it to appear on the TV Certificate)

Mailing Address: .
(Indicate if Company address)

.
.
.

e-mail address:

Phone:

Fax:

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