INSTRUCTIONS: Complete all items required below, sign the Code of Ethics, include any supporting documentation, and send it to NRSB, 14 Hayes Street, Elmsford, NY 10523  or fax it to 914-345-1169. (Certification is subject to meeting the certification requirements of NRSB’s governing document.)  

Initial Certification       _____

Renewal Certification  _____

TYPE OF CERTIFICATION (s):

Areas Serviced by State

 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___Continuous Radon Monitor (CR)    __________________

Please submit a copy of your certifications for each applicable category or if you did not participate in the EPA or State programs, please submit:

( ) Course certification documenting successful completion of an NRSB approved course, USEPA  approved or equivalent, or state approved course.

( ) A copy of your NRSB approved examination report, USEPA examination report or equivalent, or state examination report.

( ) Laboratories – List Radon Measurement Specialist affiliated with Laboratory

________________________________________________________________

2. Do you have a Quality Assurance/Quality Control document (s) available for review?

( ) Yes ( ) no (This is for information only. You are not required to submit a QA Plan.)

a. Does your QA/QC document include?

Standard Operating Procedures ( ) yes ( ) no

Worker Protection Plan ( ) yes ( ) no

a. Radon Measurement Technician _________    (1 year @ $85.00 or 2 years @ $130.00)

b. Radon Measurement Specialist  _________    (1 year @ $85.00 or 2 years $130.00

c. Radon Mitigation Specialist___________    (1 year @ $85.00 or 2 years @ $130.00)

d. Laboratory ________________    (1 year @ $85.00 or 2 years @ $130.00)

e.  Photo ID Badge _____________ ($7.50 each; Please submit 2 Passport Photos)

    TOTAL FEE ENCLOSED _________Total (All Fees are Non Refundable)

    ( ) Check Enclosed

( ) Purchase Order P.O. ______________________________

( ) VISA/ MC/AMEX #______________________________________________

Security Code: ________________Exp. Date:_______

Signature:_________________________________

Billing Address: ____________________________________________________________

Date:______________________________

The following Code of Ethics serves as an agreement with radon professionals who possess a current NRSB certification. The established rules are necessary to protect the life, health, property and welfare of the public, and to maintain the credibility of the certification program. Accordingly, each NRSB certificate holder agrees to retain full responsibility and liability for his/her actions and agree to comply with the following Code of Ethics:

Responsibility:

Protect the safety, health and welfare of the public, by performing all certified activities in accordance with properly established and approved procedures and standards adopted by the National Radon Safety Board.

Integrity:

Perform all certified activities honestly and treat the public, clients and employer in an impartial and ethical manner. All details of the certified activity shall faithfully and accurately reflect the inspections; procedures used, and result obtained.

Conflict of Interest:

Consciously avoid conflicts of interest situations and openly disclose such conflicts to all concerned parties.

Improper Conduct:

Refrain from work activities outside the area of certification without prior approval.

Safety:

Act in a safe and responsible manner while conducting certified activities, ensuring that all required and necessary safety procedures are in place and are being used by one’s self and others for whom one is responsible.

                            3.0 PENALTY

Violation of this Code of Ethics by any NRSB certified person might be cause for discontinuing certification.

I agree to abide by the above "Code of Ethics" for personnel certified by NRSB. I understand that certification does not constitute any form of license. Additionally, I release and forever discharge NRSB, a non-profit organization, and NRSB subcontractors from any and all liabilities, claims, demands, or causes of action whatsoever, which now exist or which may hereafter arise on account of my (the undersigns) activities henceforth as Certified by NRSB. I authorize the NRSB to list my certification on the Internet. The undersigned applicant further acknowledges that this release is being given as a prerequisite for having filed application for consideration by NRSB.

 

 

 

4.0 REPRESENTATIONS

Have you ever had a radon license or certification denied, suspended, revoked or not renewed by a Federal, National, or State Radon Program?

If yes, please state reasons for revocation or non-renewal.

__________________________________________________________________________________________________________

I agree to notify the National Radon Safety Board within 7 days, in writing, of any radon license or certification denied, suspended, revoked, or not renewed by a Federal, National or State Radon Program.

Signature___________________________ Print Name _________________________

Date_____________