Application Form:
Certified Air
Quality Professional
CASANZ
Clean Air Society of
Australia & New Zealand
www.casanz.org.au
Certified Air Quality Professional (CAQP)
Application Form
PART A: CONTACT DETAILS
Title:
Full Name:
CASANZ Membership No:
Email:
Employer:
Job Title:
Postal Address:
Work Telephone:
Mobile Telephone:
CASANZ adheres to the Privacy Principals as defined by the Privacy Act 1988. Details of our Privacy Policy can be located on our website.
PART B: QUALIFICATIONS
Minimum formal qualifications required:
•
An Air Quality Science related degree and related work experience:
• PhD or Masters Qualifications and a minimum of 2 years’ related work experience.
• Degree Qualifications and a minimum of 5 years’ related work experience.
• Diploma Qualifications and a minimum of 10 years’ related work experience.
Please detail your formal qualifications in the table below. Evidence of these qualifications in the form of copies is
required and must be provided with this application.
Formal Qualifications
QUALIFICATION
DISCIPLINE
INSTITUTION
COUNTRY
YEAR
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PART C: INFORMAL QUALIFICATIONS
Please detail your informal qualifications in the table below. Evidence of these qualifications in the form of copies is
required and must be provided with this application.
Informal Qualifications
QUALIFICATION
INSTITUTION
COUNTRY
YEAR
PART D: WORK EXPERIENCE
Please submit an up to date curriculum vitae (CV) to support your application. Your CV should detail: employment
records and periods of engagement; training records; and industry skills.
SUMMARY OF RELEVANT
WORK EXPERIENCE
INDUSTRY SPECIFIC
EXPERIENCE
1.
AREAS OF PRACTICE
(ODOUR MODELLING, STACK
TESTING, AUDITING,
ETC.)
2.
3.
4.
5.
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PART E: REFEREES
Please provide details of a minimum of two nominated respected environmental professionals to act as your
referees. One must be associated with your current or immediate past employment. They should be familiar with your
experience, skills and attributes as they relate to environmental practice, ethics and professional integrity.
REFEREE ONE
Name:
Company:
Relationship to Applicant (ie. supervisor):
Telephone:
Email:
REFEREE TWO
Name:
Company:
Relationship to Applicant (ie. supervisor):
Telephone:
Email:
REFEREE THREE
Name:
Company:
Relationship to Applicant (ie. supervisor):
Telephone:
Email:
Please Note: All referees will be contacted by the Professional Accreditation Review Panel (PARP).
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PART F: FURTHER EVIDENCE OF CLAIM
Further information to support your claim may be provided, including: testaments, citations, published papers, reports,
written references, and so on.
YEAR
DETAILS
DOCUMENT
Please provide details if applicable:
HAVE YOU HELD OFFICE AS A CASANZ OFFICE BEARER?
HAVE YOU HELD OFFICE IN ANOTHER ENVIRONMENT-RELATED ASSOCIATION?
HAVE YOU PRESENTED AT A CASANZ EVENT?
HAVE YOU BEEN A COMMITTEE OR PANEL MEMBER FOR A GOVERNMENT BODY, INDUSTRY
ASSOCIATION, STANDARDS AUSTRALIA, NATA, IANZ OR ANY OTHER SIMILAR ORGANISATION?
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PART G: STATEMENT OF ETHICAL CONDUCT
The Code of Ethics has been developed by CASANZ as a principle for the professional conduct of all members. All
CASANZ members must agree to abide by the Code of Ethics. It is intrinsic to the CAQP program that members
behave with the highest levels of integrity and professional conduct. Applicants are therefore asked to disclose matters
relevant to past issues of professional conduct, ethics and integrity.
CASANZ Code of Ethics & Professional Conduct
Certified Air Quality Professional members have a duty:
1. To adopt high ethical and moral standards and act to ensure the dignity, standing and reputation of his or her
profession.
2. To act only in areas in which he or she has competence and maintains a commitment to professional development.
3. To work to high professional standards and not compromise his or her professional integrity.
4. To remain objective and truthful in all professional reports, statements or testimony.
5. To strive for the advancement of professional understanding of air quality matters and contribute to the
education of others in the Society, in other professions and associations and in the community.
6. To undertake his or her professional work in a manner that will contribute to the conservation or enhancement
of the environment.
7. To uphold the safety and health of the community above private or business interests in the performance of his
or her professional duties.
8. Not to criticise any person or organisation to gain business advantage or detract from another’s reputation.
9. To advise a client, employer or colleague of any conflict of interest which may influence judgment or affect the
quality of service.
10. Not to divulge information gained from a client or from professional activities unless approved by the rightful
owner of that information.
11. Not to use, without owner consent, information or data derived or developed from another business or contract.
12. To take personal responsibility for the integrity of data collected, advice given and reports developed and shall
endeavour to prevent misrepresentation of that work.
13. To promote the Society in a professional manner to colleagues, clients and professional acquaintances and
not act in a manner which would bring the Society into disrepute.
Answering ‘Yes’ to any of the questions below does not constitute automatic non-acceptance of the application, but
will be taken into account by the Professional Accreditation Review Panel (PARP).
YES
NO
Have you ever had a professional license revoked?
Have you had a Professional Indemnity claim made against you? Are there any claims pending?
Have you ever had any certification revoked?
Have you ever been convicted of a criminal offence?
Have you ever been convicted of an offence that involved dishonesty and/or a false statement?
Have you ever been dismissed on the grounds of proven dishonesty or a false statement?
If you answered ‘Yes’ to any of the questions above, please provide details:
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PART G: STATEMENT OF ETHICAL CONDUCT (continued)
I hereby declare that the information provided on the previous page is complete, true and correct. I have read and
agree to abide by the Clean Air Society of Australia and New Zealand Code of Ethics.
Signature:
___________________________________
Date: _____________________
Breaches of Code of Ethics
If it is found that a CAQP member has breached the Code of Ethics, the CASANZ Council have the power to revoke
the certification held by that member. It will be at the discretion of the Council to reinstate the title of Certified Air
Quality Professional. Any breech of the Code of Ethics will be managed confidentially according to the CASANZ Ethics
Policy and Procedure (included on the CASANZ website).
CAQP status will be revoked immediately upon the conviction of a Criminal Offence in Australia, New Zealand or overseas.
PART H: STATEMENT OF CLAIM
The following statement of claim must be signed and dated by the Applicant and a Proposer.
To maintain certification, I acknowledge that I must achieve a minimum of 10 Continuing Professional Development
Points (or part thereof) per annum. I declare that all information on this application form and any information that is
contained in my further evidence is true, accurate and complete to the best of my knowledge. I understand and agree
that the PARP has the right to contact any person, government agency, or organisation listed in the application, to
review or confirm information. I also agree to inform the PARP, in a timely manner, if I become the subject of any
ethical or criminal offences. I understand that providing false or misleading information may result in a revocation of
certification and that the CASANZ Council has the authority to suspend or cancel my membership at any time.
Name of Applicant:
___________________________________
Date: _____________________
Signature of Applicant: ___________________________________
Name of Proposer:
___________________________________
Date: _____________________
Signature of Proposer: ___________________________________
Disclaimer: The application form and requirements to maintain ongoing Continuing Professional Development will be
reviewed from time to time and may change. The authority for a member to be certified as a CAQP remains with the
CASANZ Council.
PART I: CHECKLIST
The following documentation must be provided to support your application:
Completed Application Form
Copies of Formal Qualifications
Current Curriculum Vitae
Copies of Further Evidence of Claim
Application Fee payment details
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PART I: FEES
To be awarded CAQP status, applicants must be an Individual member or a nominated representative of an
Organisation or Sustaining membership. All memberships must be current and financial. The CAQP annual
membership fees is $295.
FEES
Fee Type
Membership Type
Australia
NZ &
Overseas
Application Fee
(Non refundable)
All Member Types
A$60
A$55
Individual Member
A$100
A$90
Organisation Member
A$195
A$175
Sustaining Member
A$195
A$175
Annual Fee*
TOTAL PAYABLE:
A$_________
A$_________
A$_________
All fees are payable in Australian dollars. GST is applicable to Australia only.
*Annual fees shown above assume the applicant is already a CASANZ member. If you are not a member, then you need to complete a member
application form or be added as a nominated representative to an Organisation or Sustaining membership.
PAYMENT (PLEASE INDICATE)
By EFT
Account Name: Clean Air Society of Australia & New Zealand Inc.
Bank:
Westpac – Eastwood, NSW
BSB:
032 080
Account No:
382024
Date Deposited: ______________________
Please use your surname as the payment reference.
By Credit Card:
Visa
MasterCard
Please debit my credit card with A$_____________ Card Number: ______________________________
CVV: ______________________
Expiry Date: ____________________ Name of Cardholder: _________________________ Signature: __________________________________ Completed applications can be forwarded to:
Email: [email protected]
Fax: 03 8677 1775
Mail: PO Box 274, Olinda, Vic 3788
INVOICE
ABN: 83 608 131 901
This document becomes an invoice after payment is made. Please retain a copy for your records.
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