2024 CPAG Member Application Form

2024 CPAG Member Application Form

Submissions will be accepted until March 15, 2024.

Please provide the following information:

Name*

Company*

City

State

Country

Email Address*

Phone Number*

AIHA Member ID*

Please indicate your member classification*

Full

Early Career Professional

International

Emeritus

Which certification(s) do you currently hold?*

Select all that apply.

Certified Hazardous Materials Manager/Practitioner

Certified Industrial Hygienist

Certified Safety Professional

Industrial Hygiene Technician Certification

Professional Engineer

No formal certifications/licenses but have specific job/workplace responsibilities for hygiene/safety/health

Other

If 'other' was selected, please specify.

Please list current services for AIHA.*

(e.g., Volunteer Groups, Board).

Please list past services for AIHA.*

(e.g., Volunteer Groups, Board).

Skills and Experience*

Include a brief statement of why your skills and experience would make you a valuable member of CPAG.

Time Commitment*

Can you commit to the time required to serve on this advisory group?

Yes

Conflict of Interest*

Do you have a Conflict of Interest form on file?

Yes

Career Stage*

Student

Early Career Professional (10 or less years of experience)

Professional (11-31 years of experience)

Senior Professional (+31 years of experience)

Please upload a copy of your CV or Resume

File Upload*

Drag and drop files here or

Diversity, Equity and Inclusion

In our efforts to be representative of our membership population, we seek to build diverse and inclusive volunteer groups. We believe when people bring their unique identities, backgrounds, perspectives, and experiences to our work, we achieve better results for everyone. With this in mind, we ask you to provide some DEI (diversity, equity, inclusion) information. Please note that you may decline to provide any information which you do not feel comfortable furnishing.

If not listed, please list:

If pronouns are not listed above, please list:

Sexual Orientation*

Do you identify as being part of the LGBTQ+community?

Yes

I do not wish to provide this information

Race/Ethnicity*

Hispanic/Latinx: A person of Cuban Mexican, Puerto Rican, South or Central American, Spain or other Spanish culture or origin regardless of race.

White (Not Hispanic/Latinx): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic/ Latinx): A person having origins in any of the black racial groups of Africa.

Native Hawaiian or other Pacific Islander (Not Hispanic/Latinx): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic/Latinx): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the India Subcontinent (Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam).

American Indian or Alaska Native (Not Hispanic/Latinx): A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Bi-Racial (Not Hispanic/Latinx): All persons who identify with more than one of the above five races.

I do not wish to provide this information.

Are you fluent in any language other than English?*

Yes

If yes, please list:

Do you identify as having a disability?*

Yes

I do not wish to provide this information

If yes, please explain.

Accessibility Measures*

Do you require accessibility measures as part of your broad application process (e.g., transcription during a virtual interview or ASL Interpreter)?

Yes

I do not wish to provide this information

Send me a copy of my responses

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