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

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