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Examination Extended application Late applicationDates Deadline Fee DeadlineOct. 6, 2012 Aug. 17, 2012 Aug. 22, 2012March 2, 2013 Jan. 11, 2013 Jan. 16, 2013Oct. 5, 2013 Aug. 6, 2013 Aug. 21, 2013

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CERTIF ICATIONEXAM APPLICATION1. ASQ M E M BERSHIP NUMBER If you are not an ASQ member, leave blank

2. NAME/A DDRESS INFORMATIONMr. Ms. Mrs. Dr. (Print clearly or type)

First Name Middle Initial Last Name

Home Address Apt./Ste.

City, State/Prov., Zip/Postal Code Country

Home Area Code and Telephone Number

Employer Name Your Title

EmployerAddress Apt./Ste.

City, State/Prov., Zip/Postal Code Country

Bus.Area Code and Telephone Number Fax Number

Email Address

3. FE ECheck the applicable box below.

MARCH/OCTOBEREXAMSCQI ................................. Retake................. 7,095/-

ASQ Member............................................... 10,395/-Nonmember................................................. 18,645/-

CQT ................................. Retake................. 7,095/-ASQ Member............................................... 10,395/-Nonmember................................................. 18,645/-

CRE ................................. Retake................. 12,045/-ASQ Member................................................ 14,795/-Nonmember................................................. 23,045/-

CMQ/O E................................. Retake................. 15,895/-ASQ Member............................................... 18,645/-Nonmember................................................. 26,895/-

CHA ................................. Retake................ 12,045/-ASQ Member............................................... 14,795/-Nonmember................................................ 23,045/-

CBA ................................. Retake................ 12,045/-ASQ Member............................................... 14,795/-Nonmember................................................ 23,045/-

CSSBB* ................................. Retake................. 14,245/-ASQ Member............................................... 16,995/-Nonmember................................................. 25,245/-

* Your Six Sigma Black Belt application will be on hold until your affidavit(s)is (are) received atASQ.

Completed affidavit(s) must be received at ASQ within one weekof receiving your application. If not, your application will be canceled and a partial refund (lessapplication fee) will be returned to you.

EXAMINATION DATEYour 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

registration fee. Applications received after the late application deadline

will automatically be processed for the next examination date.

JUNE/DECEMBEREXAMSCPGP ................................. Retake................. 12,045/-

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

CSQE ................................. Retake................. 12,045/-ASQ Member................................................ 14,795/-Nonmember................................................. 23,045/-

CQA .................................. Retake................. 12,045/-ASQ Member............................................... 14,795/-Nonmember................................................. 23,045/-

CQE ................................. Retake................ 12,045/-ASQ Member............................................... 14,795/-Nonmember................................................. 23,045/-

CQIA ................................. Retake................. 7,095/-ASQ Member.............................................. 10,395/-Nonmember................................................ 18,645/-

CCT ................................. Retake................ 7,095/-ASQ Member.............................................. 10,395/-Nonmember................................................ 18,645/-

CQPA ................................. Retake................ 7,095/-ASQ Member............................................. 10,395/-Nonmember............................................... 18,645/-

CSSGB ................................. Retake............... 8,745/-ASQ Member.............................................. 11,495/-Nonmember............................................... 19,745/-

EXAMINATIONDATESYour 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

registration fee. Applications received after the late application deadline

will automatically be processed for the next examination date.

Examination Extended application Late applicationDates Deadline Fee DeadlineDec. 1, 2012 Oct. 12, 2012 Oct. 17, 2012

June 1, 2013 April 12, 2013 April 17, 2013

Dec. 7, 2013 Oct. 18, 2013 Oct. 23, 2013

EXAM FEE TOTALSYou may pay bycheque/dd favouring American Society for QualityIndia Pvt. Ltd.Your application will be returned unprocessed if payment is not enclosed.`2,750/- of your fee is an application fee and is not refundable.If you are interested in becoming a member, include payment andthe membership application with your certification fee.

March/OctoberJune/December

TotalMethod of Payment:Cheque or DD Payable to American Society for Quality India Pvt. Ltd.

Fees subject to change without notice.If the payment amount submitted is incorrect or a price increaseoccurs, we willbill you accordingly or charge your credit card the appropriate amount.To register online, visit www.asq.org.in and click Certification.

4. EXAMINATION SITEPlease list yourASQ section number for testing location.

SectionNumber

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

City

Country ______________________________________________________________________

Please complete both sides of this application

-

INDIA CENTRE CODEMUMBAI 00 PUNE 02 CHENNAI 03 DELHI 04

BANGALORE 05 HYDERABAD 06 KOLKATA 07 AHMEDABAD08

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5.EDUCATION Complete the entire section below showing the highestcompletededucational degree or diploma you have received. Credit is notissued for nondegree education or for partially completed degreeprograms.

International applicants must provide documentation toverify educational equivalency.Degree or Diploma Year

Name of Institution

LocationofInstitutionIs this a (circle one) technical school diploma or an associate,bachelors, masters, or doctorate degree?6.WORK EXPRIENCE If you do not meet all of the necessary qualifications, you will not beallowed to take this exam.CQIAand CQPArequire TWO years of work experience oran associate degree or TWO years of equivalent highereducation.

CQIrequires TWO years of work experience. If you do not have a highschool diploma or GED, you must have THREE additional years workexperience.

CQTrequires FOURyears of higher education and/or work experience.CR E, CQA , CQE, and CSQE require EIGHT years of highereducation and/or work experience including THREE years in a

decision-making position.

CBA and CHArequire FIVE years of work experience including ONEyear in a decision-making position.

CMQ/OErequires 10 years of higher education and/or workexperience including FIVE years in a decision-making position.

CSSBBrequires TWO completed projects with signed affidavits orONEproject with signed affidavit and THREE years of work experience. Noeducation waivers are given.

CCTrequires FIVE years of higher education and/or work experience.CPGP requires FIVE years of on-the-job experience including THREE yearsin a decision-making position. No education waivers are given.

CSSGB requires THREE years of work experience.All work experience must relate to one or more areas of the body ofknowledge of that specific certification.

DECISION-MAKING is defined as having the authority to define,execute, or control projects/processes and being responsible for theoutcome.If you have been certified by ASQ in any of the areas below, please provideyour certificate number in lieu of work experience. If you are applying forthe manager exam, youll need to include additional work experience.

CQA CQE Manager CRE CSQE

Certificate Number

Date / /

The following does not apply for CQI, CSSBB, CPGP, or CSSGB.If you have completed a degree, diploma, or certificate programbeyondhigh school, you may waive some of the required experience as follows:

Certificate/diploma from a technical or 1 year,trade school CCT 2 years

Associate degree (college or technical 2 years,institute) CBA, CHA1 year

Bachelors degree 4 years,CCT 2 years,CQT, CHA, CBA 3 years

Masters/doctoral degree 5 years,

CCT 2 years,CQT 3 years,CBA, CHA 4 yearsYou must attach a rsum or provide your work experience below;employment dates must be by month/year.

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

7. COMPLANC E WITH RULES Please read the ASQ Code of Ethics below. Compliance withthe

Code of Ethics is mandatory for all certified individuals, whether or notthey are members ofASQ.

I have read, I understand, and I agree to comply with the ASQ

Code of Ethics. I agree not to discuss or release in anyform the contents

of the examination. I affirm that all information contained in this

application is correct.

Signature

Pleaseprintyourname

Date / /

ASQ CODE OF ETHICS FUNDAMEN TAL PRINCIPLES

ASQ requires its members and certification holders to conduct

themselves ethicallyby:

I. Being honest and impartial in serving the public, their employers,

customers, and clients.

II. Striving to increase the competence and prestige of the quality

profession, andIII. Using their knowledge and skill for the enhancement of

human welfare.

Members and certification holders are required to observe the

tenets set forth below:

RELATIONS WITH THE PUBLIC Article 1 Hold paramount the safety, health, and welfare of the

public in the performance of their professional duties.

RELATIONS WITH EMPLOYERS,CUSTOMERS AND CLIENTS Article 2 Perform services only in their areas of competence.Article 3 Continue their professional development throughout

their careers and provide opportunities for the

professional and ethical development of others.Article 4 Act in a professional manner in dealings with ASQ staff and

each employer, customers, or client.

Article 5 Act as faithful agents or trustees, and avoid conflicts of

interest and the appearance of conflicts of interest.

RELATIONS WITH PEERS Article 6 Build their professional reputation on the merit of their services

and not compete unfairly with others.

Article 7 Ensure that credit for the work of others is given to those to

whom it is due.

DID You Complete both sides of the application? Include payment? attach your rsum or provide your workexperience with employment dates bymonth/year?

Sign your application? Include your CSSBB affidavit(s)? (affidavits

can be found atasq.org/certification/index.aspx)

Employer

Addres s

Supervisor

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

Employer

If you have special needs that we canAddress, call ASQ Certification o fferingsat 800-248-1946 or 414-272-8575.

Address

Supervisor

Job Title From (Mo/Yr) To (Mo/Yr)

Employer

Address

Supervisor

Return this application to:American Society for Quality India Pvt. Ltd.325, 3rd Floor, DLF Tower B,

Jasola District centre, New Delhi - 110025T.: +91 11 46783399 F: +91 11 40793573

E: asqindia@asq.orgYou may also join online at

http://asq.org.in and www.asq.org

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