CompEx Certification Application Form
Personal Details
Given Name Family Name
Apartment No Building Name/No
Street Town/City
County/State Country
Post/Zip Code Date of Birth
Nationality (as shown on passport) Tel No
E Mail Job Role (Current)
Qualification for Assessment (Please select the CompEx qualification you wish to be assessed in)
Foundation Foundation Plus
ExF ExF Plus
ExF NEC500 ExF Plus NEC500
ExF NEC505 ExF Plus NEC505
Functional Safety Foundation
Core Competency & Advanced Practitioner
Ex01-Ex04 Gas & Vapours Ex01RPP-Ex04RPP Recognised Practitioner Programme
Ex05-Ex06 Dust Ex07-Ex08 Fuel Forecourts
Ex09-Ex10 Utilities Ex11 Mechanical
Ex12 Application Design Engineer Ex14 Responsible Person
MTEx01-MTEx04 Maritime Small Bore Tubing Inspection
Current/Previous CompEx Certification (Please list any previous CompEx qualifications)
CompEx Qualification Certificate Number Candidate ULN (if known)
Employer Details (Please give the full company name of your current employer)
Full Company Name
Industry Sector (Please tick the sector applicable to your current employment)
Oil & Gas Chemicals
Utilities Pharmaceutical
Food & Beverage Manufacturing
Fuel Distribution & Retail Maritime
Electrical Contractor Distributor
Other
CCL3501 CompEx Certification Application Form Rev 18 08/24 Page 1 of 2
Course Sponsorship (Please select one of the below options.
U U By ticking a selected option, you agree to the accompanying statement.)
I agree that the results of my learning and assessment can be shared with the CompEx
Employer Funded
approved training provider and my employer.
I agree that the results of my learning and assessment can only be shared with the
Self-Funded
training centre.
Candidate Declaration of Acceptance of Scheme Requirements:
In signing this application form you agree to:
• Comply with the requirements for Certification, including CCL2001 CompEx Candidate Code of Conduct.
https://compexcertification.com/wp-content/uploads/2023/11/CCL2001-Candidate-Code-of-Conduct-
28TU
Rev12-Nov-23.pdf U28T
• The processing and storage of personal data and results as detailed in the CompEx Privacy Policy (CCL2000)
and in accordance with the General Data Protection Regulations 2018.
(https://compexcertification.com/privacy-policy/)
• Registration onto the CompEx Learning Management System for access to courses (free and pay-for), a library
of videos, articles and other technical papers relating to potentially explosive atmospheres. Full details listed in
the CompEx Privacy Policy (CCL2000) (https://compexcertification.com/privacy-policy/)
Please tick here if you agree to us contacting you with information about CompEx/JTL Group products,
services, and developments, and up to date industry information. Opt out information can be found in the
CompEx Privacy Policy (https://compexcertification.com/privacy-policy/)
Candidate Signature: _________________________________________ Date:______________________________
Candidate Name: __________________________________________________________________________________
------------------------------------------------------------------------------------------------------------------
Approved Training Provider Confirmation:
We the CompEx Approved Training Provider listed below, confirm that that the candidate details, identity and
suitability for the chosen course have been confirmed.
Additional Comments
Please add any comments in relation to the suitability of the candidate (if required).
ATP Representative Signature: ___________________________________________ Date: ____________________
ATP Representative Name: ___________________________________ Centre Name: ______________________
Copyright and Trademarks
This document and all documents relating to the CompEx Certification Scheme and CompEx qualifications are copyright of CompEx Certification
Limited. All industrial and intellectual property rights, relating to CompEx qualifications and other products and services provided by CompEx
Certification Limited, including without limitation; patents, trademarks, and/or service marks (whether registered or unregistered), registered
designs, unregistered designs, copyright and database rights and rights of a similar nature by whatever name they are known in any country of
the world together with any applications for any of the foregoing in any part of the world and the copyright in all drawings, plans, specifications,
designs and computer software and all know-how and confidential information are the property of CompEx Certification Limited. © CompEx
Certification Limited. Registered in England No: 02336110. Registered Office: 120-122 High Street, Orpington, Kent BR6 0JS.
CCL3501 CompEx Certification Application Form Rev 18 08/24 Page 2 of 2
