2021-2022 CIH Impact Award Endorsement

Endorsement Form

The BGC® Impact Award is awarded to a Certified Industrial Hygienist® or Certified Associate Industrial Hygienist® who has made a significant contribution to the practice of occupational and environmental hygiene.

Note: This form is for the endorsement of a previously-nominated candidate for the CIH Impact Award. If you are looking for the Nomination Form for the Impact Award, please click here: Impact Award Nomination Form.

Question Title

* 1. Nominee’s Information (the person who has already been nominated)

Name

Certification Number

Briefly describe the Nominee’s Occupational and Environmental Hygiene accomplishments, work, and contributions which resulted in a significant impact on the profession in the last five (5) years.

Question Title

* 2. Written Justification

Question Title

* 3. ENDORSER:
By typing my name below, I certify that the above information is true and accurate to the best of my knowledge.

Name *

Title

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Daytime Phone Number *

Question Title

* 1. Nominee’s Information (the person who has already been nominated)

Question Title

* 2. Written Justification

Question Title

* 3. ENDORSER:By typing my name below, I certify that the above information is true and accurate to the best of my knowledge.

* 3. ENDORSER:
By typing my name below, I certify that the above information is true and accurate to the best of my knowledge.