BCSP Professional Mentor Form
Please note: Mentoring will only be recognized if done in addition to regular work activity.

As a mentee/applicant, please submit this form at the time that you send in your application for certification.

The mentor program rewards certificants for encouraging other safety professionals who perform quality work to demonstrate their exceptional skill by obtaining certification. When this mentor form is accepted, BCSP will:

1. Credit the mentor for assisting in the career development of the applicant
2. List the mentor in an honor roll that is published in BCSP’s eNewsletter following the year the mentor form was received
3. Reward the mentor with branded merchandise such as mugs, cups, polo shirts, and pins based on the number of people they mentor

Please fill in the information of the mentee.
Mentee Salutation
Mentee First Name (legal name)
Your answer
Mentee Middle Initial(s)
Your answer
Mentee Last Name (family name, surname)
Your answer
Certification for Which Mentee Applied
Mentee Email Address
Your answer
Mentee Company
Your answer
Mentee Title/Position
Your answer
Mentee Street Address
Your answer
Mentee City
Your answer
Mentee State/Province
Your answer
Mentee Country
Mentee Zip/Postal Code
Your answer
Mentee Phone
Your answer
Mentor Salutation
Mentor First Name
Your answer
Mentor Last Name
Your answer
BCSP Credential(s) Currently Held
Mentor Email Address
Your answer
Mentor Company
Your answer
Mentor Title/Position
Your answer
Mentor Street Address
Your answer
Mentor City
Your answer
Mentor State/Province
Your answer
Mentor Zip/Postal Code
Your answer
Mentor Country
Mentor Phone
Your answer
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