Fillable Asq Six Sigma Black Belt Certification Project Affidavit/verification Form printable pdf download

ASQ SIX SIGMA BLACK BELT CERTIFICATION PROJECT

AFFIDAVIT/VERIFICATION FORM

Please see the explanation of how to fill out this form on the reverse side

One of the requirements for application approval to take ASQ’s Six Sigma Black Belt certification exam is the

demonstration of experience. Six Sigma Black Belt affidavit(s) must be completed and submitted attesting to that fact.

Provide two signed affidavits attesting to the completion of two Six Sigma projects, signed by the project champion(s).

If two Six Sigma projects have not been completed, one completed project will be allowed providing you have at

least three years of work experience covered by the Six Sigma Black Belt Body of Knowledge (BOK).

❏ Check here if two projects have been completed.

❏ Check here if DFSS project.

❏ Check here for one completed project and three years’ experience.

If you have not completed at least one Six Sigma project, you will not be allowed to take the examination.

Completed, signed affidavits can be faxed to Certification Offerings at 414-298-2500 or e-mailed to .

The signed Six Sigma affidavit(s) must be received at ASQ within one week of receiving your application. If not,

your application will be cancelled and a partial refund (less the application fee) will be returned to you.

1. Six Sigma Project completed by ________________________________________________________________________

(applicant’s name, please print)

(member number)

2. Six Sigma project title _________________________________________________________________________________

3. Provide a brief description of the purpose of the project, and how it related to the business objective:

___________________________________________________________________________________________________

4. Six Sigma project’s start and completion dates by month/year: ______________________________________________

5. Provide a brief description of applicant’s hands-on performance in completing Six Sigma project. Please include specific

examples of tools used and how they were applied, i.e., process maps, metrics (DPU, DPMO, RTY), procedures, charts, etc.

Do not send documentation.

___________________________________________________________________________________________________

6. Provide a brief statement on the benefits achieved by the successful completion of the project, including but not limited

to financial savings, labor, material costs, cycle-time reduction, etc.

___________________________________________________________________________________________________

7. Verification of completion by project champion:

Verification form completed by: ___________________________________________________________________________

(project champion’s signature)

(date signed)

Champion’s name____________________________________________ Job title ___________________________________

Company name ________________________________________________________________________________________

Address _______________________________________________________________________________________________

Project champion’s e-mail address _________________________________________________________________________

Project champion’s telephone __________________________________

Asq Six Sigma Black Belt Certification Project Affidavit/verification Form