Membership Application

American Society of Safety Engineers

The Resource for OSH Professionals
Founded in 1911, the American Society of Safety Engineers (ASSE), is the worlds oldest professional safety
society. ASSE promotes the expertise, leadership and commitment of its members, while providing them with
professional development, advocacy and standards development. Our members create safer work environments
by preventing workplace fatalities, injuries and illnesses.

www.asse.org/membership
customerservice@asse.org
 Networking
Best Practices Join Today!
Professional Development
ASSE offers a wide range of benefits to 37,000+ GROW YOUR NETWORK EARN RECERTIFCATION POINTS AND CEUs
members from a variety of industries. Whether ASSE members find great value from having access Just being an ASSE member earns you recertification
you are a young professional just starting your to OSH professionals across the country and around points! Plus there are many other ways to earn
the world. Utilize your local Chapter, the Member points including: Chapter participation, writing for
career, or a seasoned professional looking for Directory or one of nearly 30 specialty groups to ASSE Publications and volunteering opportunities.
growth, we are committed to providing you help you find the right solution to a problem or to Not certified? ASSE offers member pricing on
with the resources and connections you need build your professional safety network. certification prep workshops. You can earn CEUs
for ASSE professional development events and
to do your job better. ENHANCE YOUR SKILLS webinars.
READ THE BEST Your educational needs may vary from specific
Professional Safety is a member-only, peer-reviewed, safety related topics, like risk management AND THERES MORE
or lockout/tagout, to general leadership and Members can access 12,500+ pieces of content
monthly publication written by practicing OSH
communication topics. ASSE covers it all. Take through ASSEs Body of Knowledge, they can help
professionals. The journal will keep you on top of the
advantage of member pricing for in-person and shape the future of OSH through volunteering, and
latest trends, best practices, research, regulations
online education, and members receive a free they receive discounts on books, standards, industry
and so much more! Plus, you can access even more
download of the proceedings from the annual products and more.
information through the Journals online archives.
Professional Development Conference.

INDUSTRY CODES & JOB TITLE CODES (LISTED IN ALPHABETICAL ORDER. PLEASE CHOOSE THE CODE THAT IS CLOSEST TO YOUR CURRENT INDUSTRY)
CODE INDUSTRY
A01 Agriculture/Forestry/Food A16 Transportation 08 Branch/District/Div/Area/Regional Mgr
A02 Chemical/Allied Products A17 Utilities Safety
A03 Communications A18 Wholesale Trades 09 Branch/District/Div/Area/Regional Mgr
A04 Computer/Electrical A19 Other/Non-Classifiable Establishments All other areas
A05 Construction 10 Dean/Dept Head/Professor/Asst or Assoc
A06 Governmental/Public Sector CODE JOB Professor
A07 Healthcare 01 President/Owner/Partner 11 Administrator/Commissioner
A08 Insurance/Risk Management Services 02 General Manager/Executive VP Safety 12 Supervisor
A09 Manufacturing 03 General Manager/Executive VP All other 13 Safety Specialist/Engineer
A10 Mining areas 14 Inspector/Compliance Officer
A11 Non-profit/Membership Organizations 04 Dir/Mgr/Dept Head/Chief Safety 15 Technical/Surveyor/Hygienist
A12 Oil, Gas, Petrochemical 05 Dir/Mgr/Dept Head/Chief/Supt 16 Consultant/Advisor/Analyst
A13 Services - Retail Personnel 17 Representative, Sales Rep
A14 Service - Other 06 Dir/Mgr/Dept Head/Chief Industrial 18 Other
A15 Services - Travel/Recreation 07 Dir/Mgr/Dept Head/Chief All other areas

EXPERTISE CODES & ADDITIONAL DESIGNATIONS/ACCREDITED CERTIFICATION CODES

CODE EXPERTISE
100 Accident Investigation/Reconstruction 2400 Generalist/Comprehensive 4700 Radiological Protection
300 Air/Water Pollution 2470 Hazard Analysis 4750 Recordkeeping/Reporting/Statistics
450 Asbestos/Asbestos Abatement 2500 Hazard Communication 4770 Regulatory/OSHA-MSHA Surveys
200 Audits 2600 Hazardous Waste Disposal/Management 4800 Risk Management
475 Aviation 2750 Healthcare 5000 Security
750 Chemical Hazards 2875 Indoor Air Quality 4925 Slips, Trips & Falls
800 Chemical Process Safety Management 2900 Industrial Hygiene/Biological Monitoring 5150 Speaker/Seminar Leader
700 Chemicals/Flammable Liquids 3000 Inspections 5200 Standards/Compliance
900 Claims Management/Workers 3050 International 5300 System Safety/MORT
Compensation 3055 Laboratory Safety 5400 Transportation
1100 Confined Spaces 3200 Legal & Regulatory Safety Issues 5650 Utility
1200 Construction 3250 Life Safety From Fire 6000 Others
1225 Consulting 3275 Lockout/Tagout
1240 Court Testimony/Expert Witness 3300 Machine Guarding ADDITIONAL DESIGNATIONS/
CODE ACCREDITED CERTIFICATION
1250 Crane Safety 3400 Management/Administration of Safety
1300 Disaster Planning 3450 Marine/Longshoring ARM Associate in Risk Management
1400 Education/Training 3500 Material Handling ASP Associate Safety Professional
1500 Electrical/Lockout Tagout 3700 Medical Service/First Aid/CPR CET Certified Environmental, Safety and
1550 Emergency Planning/Response Programs 3750 Mining Safety Health Trainer
1600 Engineering 3800 Motor Vehicle/Fleet Operations CPCU Charter Property and Casualty Underwriter
1850 Environmental Audits 3850 OSHA Compliance CSHM Certified Safety and Health Manager
1900 Environmental Control 4000 Personal Protective Equipment GSP Graduate Safety Practitioner
2000 Environmental Hazards 4050 Petroleum/Pipelines LCS Loss Control Specialist
2050 Environmental Training 4300 Product Safety REA Registered Environmental Assessor
1700 Ergonomics/Human Factors 4200 Program Evaluation REHS Registered Environmental Health Specialist
2100 Facilities & Equipment Design 4400 Psychological/Behavioral STS Safety Trained Supervisor
2200 Fall (from elevation) Protection 4650 Public Safety
2300 Fire Prevention/Protection 4450 Public Utilities
DEMOGRAPHICS (*DENOTES OPTIONAL FIELD) CODES/DESIGNATIONS

Name________________________________________________________________________________________ (See opposite page for details.)

First Middle Initial Last
Current Industry Code:____________________
Date of Birth* _________________ Gender* _ Male Female Last four digits of Social Security* __________
Current Job Title Code:____________________
Ethnicity*
From the expertise codes, select up to three
African American/Black  Caucasian  Native American
codes that best describe your area(s) of ex-
Asian/Pacific Islander  Hispanic/Latino  Other ethnic background pertise:
Mailing Address: (please complete both sections) Preferred Mailing Address: Business Home __________ __________ __________
Business Address: From the additional designations and other
accredited certification codes, select up to
Title_____________________________________________________________________________________ three additional codes:
Organization______________________________________________________________________________ __________ __________ __________
Street____________________________________________________________________________________
City___________________________________ State/Province ______________________________________ OCCUPATIONAL
Zip/Postal Code________________________________ County______________________________________ EXPERIENCE
Country__________________________________________________________________________________
Check all that apply.
Phone ( )__________________________________ Fax ( )______________________________
I have at least 5 years of OSH experience
E-Mail____________________________________________________________________________________ whereby at least 50% of my employment
Home Address: is in identifying and evaluating hazardous
conditions/practices, hazard control design,
Street____________________________________________________________________________________ procedures and program development or
implementation and development.
City___________________________________ State/Province______________________________________
I have at least 10 years of OSH experience
Zip/Postal Code________________________________ County ______________________________________ whereby at least 50% of my employment
is in identifying and evaluating hazardous
Country __________________________________________________________________________________ conditions/practices, hazard control design,
procedures and program development or
Phone ( )__________________________________ Fax ( )______________________________ implementation and development.
E-Mail ___________________________________________________________________________________ I spend at least 20% of my employment
Professional Safety Journal: Digital Print If a box is not checked, Professional Safety Journal will be digital. time in identifying and evaluating hazardous
conditions/practices, hazard control design,
procedures and program development or
implementation and development.
EDUCATIONAL HISTORY
College/University____________________________________________________________________________ SPONSOR
City______ ___________________________ State ______________________ Country______________________
Degree(s): Associate BS MS PhD EdD Other ___________________________ Sponsor Name _________________________

____________________________________
Please check applicable accredited certifications and licenses recognized for professional membership, and include
identification number(s):
Sponsor ID# ___________________________
Canadian Registered Safety Professional (CRSP) # ______________________________________________
Certified Fire Protection Specialist (CFPS) # ___________________________________________________ A sponsor is not needed for membership.
Certified Industrial Hygienist (CIH) # ________________________________________________________
Certified Hazardous Materials Manager (CHMM) #______________________________________________ HOWDIDYOU
Certified Health Physicist (CHP) #___________________________________________________________
Certified Human Factors Professional (CHFP) # ________________________________________________
HEARABOUTUS?
Certified Occupational Health Nurse (COHN) # ________________________________________________
Certified Occupational Health Nurse - Specialist (COHN-S) #______________________________________ ASSE Email
Certified Professional Ergonomist (CPE) # ____________________________________________________ ASSE Website
Certified Professional Environmental Auditor (CPEA) # __________________________________________ ASSE Brochure
Certified Safety and Health Manager (CSHM) #________________________________________________ ASSE Chapter Meeting
Certified Safety Professional (CSP) #_________________________________________________________ ASSE Educational Event
Certified User Experience Professional (CUXP) # _______________________________________________ A friend
Construction Health and Safety Technician (CHST)#_____________________________________________ Industry tradeshow
IOSH Chartered Fellow (CFIOSH) # _________________________________________________________ Professional Safety
IOSH Chartered Member (CMIOSH) #________________________________________________________ Other trade publication
Occupational Health and Safety Technologist (OHST)# __________________________________________ Other, please specify:
Professional Engineer (P.E.) #______________________________________________ State ___________ _______________________

NOTE: For designations/certifications and educa-

tion noted on this application please include verifi-
cation documentation. Certifications will be verified
and subject to a periodic audit with the certifying
body.
 MEMBERSHIP CLASSIFICATION PAYMENT INFORMATION

Residents outside the U.S. should use the Global Membership Application. Please Please check the appropriate boxes:
check one membership type based on your work history, schooling, and designations:  One-Year Society Membership
Associate Member (U.S. only)
Annual Dues $150.00 USD $___________
Provides services to the OSH profession or cooperates with safety professionals.
Chapter Dues $ 15.00 USD $___________
Global Member One-time application fee $ 25.00 USD $___________
Requires applicants to be engaged in the broad practice in OSH and reside
outside the U.S. SUBTOTAL $190.00 USD $___________
Member (U.S. only)
Requires current employment in OSH or one of its relevant specialties. Practice Specialty(ies) $20.00 USD each USD $___________
Common Interest Groups $10.00 USD each USD $___________
Professional Member
Shall have one of the following qualifications: Contribution to the ASSE Foundation USD $___________
Recommended donation: $25.00 USD
CSP or CIH designation
One of the following designations: CFIOSH, CFPS, CHFP, CHMM, CHP, CHST,
CMIOSH, COHN, COHN-S, CPE, CPEA, CRSP, CSHM, CUXP, OHST, P.E. and a
bachelors degree from an accredited college or university and five years of TOTALAMOUNTDUE USD $___________
OSH experience
Doctorate degree from an accredited college or university in OSH in a
Method of Payment : Payment required to process.
recognized field and five years of OSH experience
(U.S. funds drawn on U.S. bank or charge authorization)
Chapter Preference __________________________________
Please check one of the following:
(If no chapter preference is indicated, one will be assigned by the location of the
preferred mailing address.) Check/money order payable to ASSE

Reduced membership rates are available for students, active military personnel and VISA MasterCard American Express Discover
current ASSE members who have retired. Visit www.asse.org/memqual for details.

PRACTICESPECIALTIES (OPTIONAL) Card Number Expiration Date

These niche groups complement ASSEs broad-based activities with focused, tech- Cardholders Name (please print)
nical programs. Visit www.asse.org/ps for details. There is a $20.00 USD annual fee
for each practice specialty. Branch dues are covered by membership within the
corresponding specialty.
Please check which you would like to join: Cardholders Signature
Academics Management Note: ASSE dues are not deductible as a charitable contribution for federal
Construction Human Resources Branch tax purposes, but may be deductible as a business expense.
Consultants Manufacturing
Engineering Food and Agribusiness
Environmental Mining
Ergonomics Oil and Gas
SIGNATURE
Fire Protection Public Sector
Healthcare Military Branch
Health & Wellness Branch Risk Management/Insurance
Industrial Hygiene Training and Communications
International Transportation
Utilities
Applicants Signature Date

By submitting this form you are signifying that all statements made on this applica-
COMMON INTEREST GROUP (OPTIONAL) tion are correct. If elected to membership, you agree to abide by the Society Bylaws
and Code of Professional Conduct. Falsification of application information is grounds
Join a Common Interest Group and network with like-minded safety profession- for dismissal. Membership fees are non-refundable and non-transferable. Member-
als. There is a $10.00 USD annual fee for each common interest group:
ship is on an individual basis
Blacks in Safety Engineering BISE
www.asse.org/practicespecialties/bise
Safety Professionals and the Latino Workforce SPALW
www.asse.org/practicespecialties/spalw Return application to:
Women in Safety Engineering WISE ASSE, 33477 Treasury Center
www.asse.org/practicespecialties/wise Chicago, Illinois 60694 U.S.A.
Young Professionals in SH&E
www.asse.org/practicespecialties/yp
Apply Online: www.asse.org/join
Phone: +1.847.699.2929
Fax: +1.847.768.3434
customerservice@asse.org
Promo Code _______________________________________