Eligibility Requirements
Training
HW / SW Design acc. to IEC 61508
Date
June 17, 2014 to June 20, 2014
Comment [MY1]: 受講されたコース開催日をご
記入ください。
Location
Yokohama, Japan
Comment [MY2]: 受講されたコースの開催場所
をご記入ください。
Name of Participant
Your name
Please fill in this form sheet and give information about:
1. 3 years of your job experiences in
the field of functional safety
2. University degree or equivalent
engineer level responsibilities status
as confirmed by your employer
1. Functional Safety Relevant Experience
(please indicate information even if you have less than 3 years of job experience in Functional Safety.)
Position/Title
None
Company Name
ABC Company
Start date:
July 2007
Description of duties
Location
Odawara City, Kanagawa
Developed HW architecture for embedded control system
End date:
August 2008
Total # months:
12 months
Comment [MY3]:
＜関連する経験（例）＞
機能安全との関わりが分かるような内容をご記
入ください。
■安全関連業務
- Designed and implemented a SW control algorithm
for steering
- Participated / coordinated / Performed FMEA /
FTA / reliability analyses on system design
■検査関連業務
- Test design for electronic control units
Supervisor / Manager Name:
Taro Yamada
1
■規格関連業務
- Participating in IEC 61508 standardization work
＜関連のない経験（例）＞
-Responsible for updating corporate web pages
-Responsible for financial controlling of the control
system department
Functional Safety Relevant Experience (continued)
Position/Title
Assistant Manager
Company Name
123 Co., Ltd.
Start date:
September 2008
Description of duties
Location
Mitaka City, Tokyo
End date:
Current
Total # months:
32 months
Supervisor / Manager Name:
Hanako Yamada
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
End date:
Total # months:
Supervisor / Manager Name:
2
Location
2. University Degree (minimum Bachelor’s) in relevant field.
University
or
College
Technical field
(major)
Engineering
Name:
Degree earned
Date
Master’s degree
Certificate or
Diploma
March 2005
The University of
Tokyo
Copy attached
(check box)
City:
Bunkyo-ku,
Tokyo

Country:
Japan
or
Company
Technical field
Title/ Responsibility
Date
Company
Certification
Name:
Signed letter
attached*
(check box)
City:
Country:

*Letter should be on Company letterhead and signed by a manager level official.
Please fill in this table accordingly:
Applicant Name
Total number of years of relevant Functional Safety
experience:
3 years and 8 months
………………………………..
Your name

Compliance to TÜV Rheinland
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
FS Engineer TÜV (Rheinland) certificate any time in the
future.
Signature/Date
Please sign and write the date
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Information for
FS Engineer (TÜV Rheinland) Certificate
Please type or write in block letters
Full name
(as you would like it to appear on the
FS Engineer (TÜV Rheinland)
certificate)
Company
Mailing Address
(not a P.O. Box address)
e-mail address
Phone
Fax
Comments
First name Last name
Your current company
Your company’s addresses
Your contact e-mail
Your contact phone number
Your contact fax
If any
Please fill in this table with due diligence. If information is missing, the FS Engineer (TÜV Rheinland)
certificate cannot be issued to you.
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