Personal Information

SCAMPI Lead Appraiser and SCAMPI B&C
Team Leader Certification Application
Please check the certified role for which this application will be considered:
SCAMPI Lead Appraiser for Development
SCAMPI Lead Appraiser for Acquisition
SCAMPI Lead Appraiser for Services
SCAMPI High Maturity Lead Appraiser
SCAMPI B&C Team Leader for Development
SCAMPI B&C Team Leader for Services
SCAMPI B&C Team Leader for Acquisition
Please check the certified roles that you currently hold.
☐ SCAMPI Lead Appraiser for Development
☐ SCAMPI Lead Appraiser for Acquisition
☐ SCAMPI Lead Appraiser for Services
☐ SCAMPI High Maturity Lead Appraiser
☐ SCAMPI B&C Team Leader for Development
☐ SCAMPI B&C Team Leader for Services
☐ SCAMPI B&C Team Leader for Acquisition
☐ Introduction to CMMI for Development Instructor
☐ Introduction to CMMI for Services Instructor
☐ CMMI-DEV Level 2 for Practitioners Instructor
☐ CMMI-DEV Level 3 for Practitioners Instructor
☐ Acquisition Supplement for CMMI for Development Instructor
☐ Development Supplement for CMMI for Services Instructor
☐ Services Supplement for CMMI for Development Instructor
This application has several sections that must each be completed before the form will be
processed:
1. Contact and sponsoring Partner information
2. Information about your education, appraisal experience, domain experience, etc.
3. Commitment to the CMMI Institute Code of Professional Conduct
4. Confirmation of data submission and signature
All information and supporting documentation must be in English.
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SECTION 1
Contact Information
First Name
Last Name
Preferred Email Address
Title (Mr., Mrs.,
Ms., Dr.)
Rank (if
applicable)
Fax Number
Phone Number
Preferred Mailing Address
City
State/Province
& Country
Postal Code
Current Employer Name
Employer City
Employer
State/Province
& Country
Postal Code
Information about your sponsoring organization
Sponsoring Partner Organization
Street Address
Division, Department, or Branch
City
State/Province
& Country
Postal Code
A Sponsorship form has been submitted by my sponsoring organization Business Point of Contact
to the CMMI Institute.
Yes ______
No_____
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SECTION 2
Information about your education
Provide the following information regarding your attendance in the required courses for your certification
program. These requirements are listed on the relevant CMMI Institute Certification pages.
Dates Attended
Course Title
Instructor
Location
Instructor
Location
Instructor
Location
Instructor’s Organization
Dates Attended
Course Title
Instructor’s Organization
Dates Attended
Course Title
Instructor’s Organization
Provide the following information regarding your educational background. Candidates must have a
Bachelor’s degree in a related technical area (such as systems engineering or software engineering), or
equivalent experience.
Highest Degree Attained
College or University
Street Address
Dates Attended
City
State/Province Postal Code
Next Highest Degree Attained
College or University
Street Address
Dates Attended
City
State/Province Postal Code
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CMMI Institute Active Certification(s)
Sponsoring Organization
Street Address
City
State/Province Postal Code
Other Applicable Active Certification(s)
Sponsoring Organization
Validity Period
Street Address
City
State/Province Postal Code
Appraisal and ATM Experience
SCAMPI LA and B&C Team Leader Applicants: Provide evidence of having participated as an appraisal
team member on at least two SCAMPI A appraisals, or one SCAMPI A appraisal and two SCAMPI B and/or
C appraisals. Experience listed must have occurred within the last 24 months and must be on file in the
SCAMPI Appraisal System (SAS).
High Maturity LA Applicants: Provide evidence of having led at least two CMMI SCAMPI A appraisals and
participated as an appraisal team member on at least one High Maturity SCAMPI A appraisal. Experience
listed must have occurred within the last 24 months and must be on file in the SCAMPI Appraisal System
(SAS). Note: CMM appraisal experience will not be accepted.
Dates
CL/ML
Appraisal #
SCAMPI Class
Location
CL/ML
Appraisal #
SCAMPI Class
Location
CL/ML
Appraisal #
SCAMPI Class
Location
Appraised Organization
Dates
Appraised Organization
Dates
Appraised Organization
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Domain Experience
Provide evidence of your domain-specific experience as required by your certification program in the space
below. These requirements are listed on the relevant CMMI Institute Certification pages.
SCAMPI LA and B&C Team Leader Applicants: Provide evidence of training and/or experience in
classroom presentation and management skills, including presenting procedural and conceptual
information in a clear and concise manner and facilitating group discussion and interaction using
instructional media presentation (audio/visual) systems and aids.
SCAMPI LA and B&C Team Leader Applicants: Provide evidence of at least 10 years of project
management and engineering experience in systems or software. At least two of these 10 years must
include management of technical personnel.
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High Maturity LA Applicants: Provide evidence of experience working in a high maturity process
improvement environment in one of the following two areas:
◦Developing/facilitating high maturity training at an organization
◦Statistical/quantitative management, or modeling & simulation experience in direct support of
managing/building products
SCAMPI LA for Services Applicants: Provide evidence of at least 10 years of experience as an employee
and/or manager/supervisor in a services environment. Three of the 10 years of services experience must
be in a non-CMMI environment; at least two of the 10 years must be managing a service. Experience may
include volunteer or community service.
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SECTION 3
A signed copy of the CMMI Institute Code of
Professional Conduct has already been
submitted to the CMMI Institute
Yes ______
No_____
Code of Professional Conduct Commitment Form for Individuals
CMMI Institute Code of Professional Conduct Commitment Form for Individuals
All individuals who wish to become authorized or certified must complete this form before being
permitted into an advanced training class or before an authorization or certification will be given. If you
have any questions, please send email to [email protected]
Last Name (Family Name) ____________________________________________________
First Name _________________________________ Middle Name _________________
Phone Number __________________ Email Address _____________________________
Primary Partner Sponsor Organization _____________________________________
CMMI Institute Product Suites (Please check all that apply)
CMMI
SCAMPI
PCMM
Commitment:
I am committed to the Code of Professional Conduct for CMMI Institute Services (the Code). I
understand that by making this selection, I am agreeing to abide by the Code for all of my current and
future CMMI Institute authorizations and/or certifications.
I am NOT committed to the Code of Professional Conduct for CMMI Institute Services (the Code). I
understand that by making this selection, I am not agreeing to abide by the Code. I further
understand that my CMMI Institute authorizations and/or certifications and/or candidacies will be
discontinued within 30 days of the submission of this form.
Signature ______________________________________ Date ____________________
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SECTION 4
By signing this application:
 I have read, understand, and accept all the applicable certification policies of the
CMMI Institute
 I have read, understand, and accept the terms and responsibilities outlined in the
COPC for Individuals
 I declare that all the information on all of the pages of this application is true and
accurate. I understand that misrepresentations or incorrect information provided
can result in disciplinary action(s), including suspension or revocation of my
eligibility or credential(s).
______________________________
Signature
______________________________
Date
______________________________
Print Name
Please sign and return this form and any supporting documentation to the CMMI Institute by
one of the following means:
Postal Mail:
Certification Program Administrator
CMMI Institute
11 Stanwix Street
Suite 1150
Pittsburgh, PA 15222
Email:
[email protected]
Fax:
Certification Program Administrator
412.282.4030
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