Third-Party Verification of Required Commissioning Projects

September 12, 2020ACG

Third-Party Verification of Required Commissioning Projects

For my application as an ACG Certified Commissioning Authority (CxA), it is a prerequisite that I submit projects demonstrating my commissioning experience. To fulfill ANSI requirements, this information must be objectively verified by someone other than myself. I have listed you as someone able to attest to my work on this project, and would appreciate you completing this form at your earliest convenience.

Commissioning Project
Project Description
Employer Name:*
Project Name:*
Project start date:*
MM slash DD slash YYYY
Project end date:*
MM slash DD slash YYYY
Your Role:*
Contact Information for Individual Authorized to Verify Applicant’s Work
Name*
Position/Job Title*
Relationship to Applicant*
CxA Applicant Name*
Phone Number*
Email Address*
Enter Email Confirm Email
Client Description
Client Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
For this Commissioning Project, in which of the following activities did you participate (check all that apply)?
For this Commissioning Project, in which of the following activities did you participate (check all that apply)?*
- Development of an OPR/CFR
- Development of commissioning plan
- Review of a design
- Perform field verification
- Oversee performance testing
- Correction of deficiencies
- Coordination of facility operator training
- Prepare commissioning report
THIRD-PARTY VERIFIER USE ONLY
I attest to the accuracy of the applicant’s project experience as shown above.*
- I attest to the accuracy of the applicant’s project experience as shown above.
Signature*
Position*
Date*
MM slash DD slash YYYY
Contact Phone Number*

Third-Party Verification of Required Commissioning Projects

Membership & Certification

Third-Party Verification of Required Commissioning Projects

Membership & Certification

Commissioning Project

THIRD-PARTY VERIFIER USE ONLY