TÜV SÜD South Asia – Member of TÜV SÜD Group

Personnel Certification – Academy

1. Application

I apply for Functional Safety personal certification in accordance with IEC 61508 and IEC 61511
Functional Safety Engineer (Level 01)
Functional Safety Certified Professional (Level 02)
Functional Safety Expert (Level 03) (not published)

2. Personal details of the applicant:

Name: ………………………………………………..……. Surname: ………………..……………………

Address: …….………………………..…..................……….………………………..…..............……….……………………

City / State / Pin code:…...............……….………………………….………………………..…..............……..…..………...

Email id: ………………………………..…………………………………………..……………………………………………

Mobile no.: ……………………………………….….... Date of Birth (DD-MM-YY): …………………………………………

3. If applicable, please mention the name of the trainer and training institute from where you have completed the
training.
Name of institutioin Name of trainer Name of the course Start date of training End date of training

4. Upon completion of the certification requirements, do you wish to have your name, certification level, city of residence
and email id published on TÜV SÜD’s website?
☐...Yes ☐...No

5. Do you need special assistance or suffering or having limitations from the below given conditions, then you may
inform to our office for support at least 7 days in advance. (provide a copy of documented evidences)
☐... Language of examination is not your native language and hence time to respond in the exam may be more
than specified.
(For the applicant, whose nationality is different from Indian, provide evidence)
☐...Suffer from particular disabilities, for example dyslexia, muscular dystrophy, etc., which adversely affect
their ability to complete the examination in the allotted time. For temporary disability like fracture, illness,
etc., a candidate shall wait until he recovers and give exam at another scheduled dates.
(provide Medical certificate and demonstrate your occupancy in the instrument, chemical and process
industry, accordingly TUV SUD shall arrange your examination)

6. Declaration of applicant:

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 TÜV SÜD South Asia – Member of TÜV SÜD Group
Personnel Certification – Academy

a) The applicant commissions TÜV SÜD South Asia, Certification Body of Persons, to verify its competence as set
forth in the EN ISO/IEC 17024 standard (certification of persons) and issue a certificate of competence for the
above certification field.
b) The applicant is aware that his/her personal details (name, first name, academic title, place of birth, date of birth,
address including zip/postal code, house number and street, name and address of the client, examination venue,
date of examination, certificate number and certificate area) will be stored and processed for the intended
purpose.
c) The applicant is aware that TÜV SÜD South Asia, Personal Certification, must provide information about the
validity of the Functional Safety personal certification on request by interested third parties, while observing data
protection regulations.
d) The applicant is not entitled to use TÜV SUD logo. There is no mark for the functional safety certification
scheme.
e) The applicant is aware that his/her result and certification will be withheld subject to incomplete application form
and non – fulfilment of certification requirements.

7. Self-disclosure for the certification of Functional Safety

a) The applicant confirms that he/she fulfils the prerequisites in accordance with the scope of certification of the
respective scheme applied for, to sit in the examination.
b) The applicant confirms that he/she shall inform to certification body without any delay , of matters that can affect
the capability of the certified person to continue to fulfil the certification requirements.
c) The applicant confirms that, after achieving the certification, if the certification of the certified candidate is
suspended than the candidate is refrained for further promotion of certification.
d) The applicant confirms that after achieving the certification, in the event of withdrawal, the certified candidate
refrains from the use of reference to a certified status.

8. Applicant shall refer the table below and ensure that pre-requsite for applied level of examination is fulfilled.
A copy of documented evidence of completed relevant training and/or a confirmation issued by the employer of work
experience in accordance with the IEC 61508/IEC 61511 must be enclosed with the application wherever applicable.

Level 01: (as applicable)

Information about training and/or professional experience Mention Professional qualifications or experience as

Certificate of Diploma in engineering or Bachelor of

engineering or equivalent degree. ……………………………………………................
*provide soft copy to demonstrate
Attended functional safety training for minimum of 24 Hours
……………………………………………................
Minimum of 4 years of experience in process industry
(operations, engineering or consulting) (submit work ……………………………………………................
experience certificate or self attested profile containing years
of work experience) OR
Candidate holding diploma in engineering shall have minimum
of 6 years of experience

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 TÜV SÜD South Asia – Member of TÜV SÜD Group
Personnel Certification – Academy

Level 02: (Not applicable for this training course)

Information about training and/or professional experience Mention Professional qualifications or experience as

Valid certificate of FSEr

*provide soft copy to demonstrate ……………………………………………................
Confirmation of 6 years of relevant industry work experience :
the pre-requisite of 6 years of experience is dependent of
academic qualifications:
- 2 years is deducted if applicant is M. Tech in
engineering or equivalent post graduation
- Doctoral ( Ph D ) is considered equivalent to ……………………………………………................
two years of experience
Evidence of completion of at least 2 HAZARD analysis / SIL
determination studies / LOPA studies as a participant +
Hands on experience on at least 2 case studies which is
endorsed by the applicant’s employer and reviewed by TUV ……………………………………………................
SUD’s subject matter expert

9. I accept to perform my duties by accepting the following Code of Ethics of TUV SUD South Asia – Personal
Certification
a) TÜV SÜD South Asia Personal Certification requires its certificate holders to conduct themselves
professionally, with honesty, impartiality, accurateness, responsibility and independence.
b) TÜV SÜD South Asia Personal Certification’s certificate holders should use their knowledge and skills for the
enhancement of human welfare.
c) TÜV SÜD South Asia Personal Certification’s certificate holder’s performance of their professional duties
should include safety, health and welfare of public.
d) TÜV SÜD South Asia Personal Certification’s certificate holder should perform their service only in their areas
of competence and should avoid conflict of interest
e) TÜV SÜD South Asia Personal Certification’s certificate holder should not plagiarize and shall respect the
intellectual property of others and do not use them without permission.
f) TÜV SÜD South Asia Personal Certification’s certificate holder undertake only those assignments for which
they are competent by virtue of certification, training, and experience and, where warranted, seek the
assistance of specialists as required to complete of assignments;
g) TÜV SÜD South Asia Personal Certification’s certificate holder indicate to the employer or supervisor any
decisions that have been overruled by any authority that could result in adverse consequences;
h) TÜV SÜD South Asia Personal Certification’s certificate holder should not to use the certification in such a
manner as to bring the certification body into disrepute, and not to make any statement regarding the
certification which the certification body considers misleading or unauthorized;
i) TÜV SÜD South Asia Personal Certification’s certificate holder should discontinue the use of all claims to
certification that contain any reference to the certification body or certification upon suspension or withdrawal
of certification, and to return any certificates issued by the certification body;

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 TÜV SÜD South Asia – Member of TÜV SÜD Group
Personnel Certification – Academy

10. Course Schedule & Payment:

Course dates: Training - 29th April to 1st of May 2019, Examination - 2nd May 2019
Venue: Grand Mercure Surya Palace Hotel, Sayajigunj, Vadodara (Gujarat)
Course Fees: Rs. 50,000 /- (Tea/Coffee, Breakfast & Lunch are included for all 4 days)
ISA members - 5% discount
Early bird special - 5% discount for registration by 13/04/2019
The class size is limited to 22 attendees.
Payment: All payments to be made in favour of “I S A – Gujarat Section” prior to the training dates.
1. Cheque payable to “I S A - Gujarat Section” OR
2. NEFT/RTGS to ISA-Gujarat Section account below:
Bank: SBI
Branch: Alkapuri, Vadodara
A/C: 10344691297
IFSC: SBIN0003321
Mailing Addr: You may send completed and signed Registration Form and/or Cheque to:
Jagdish Shukla
'Nirmal' 94, Mangalmurti Society
Opp. Mother's School, Gotri Road, Vadodara - 390 021

I am aware that incorrect details or misuse of the certificate can result in certificate withdrawal.
I hereby declare that all details given in this document are complete.
I also accept my duties, declarations, self disclosure and all the terms and conditions mentioned in this application form.

Place: ...................................................... Date: ………………..…..…Applicant (Name + Signature):……………………..

11. Note by the Personal Certification Team: (stage 01)

Confirms information on pre-requisites and certification requirements:

Yes
No

Date: ……………… (Name + Signature): ……………………

12. Note by the Personal Certification: (stage 02)

Verified and Confirms the receipt of pre-requisites and certification requirements:

Yes
No

Date: ……………… Controller of examination (Name + Signature): ……………………

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 TÜV SÜD South Asia – Member of TÜV SÜD Group
Personnel Certification – Academy

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