Fillable Form 150: SBE CERTIFICATION Application

Fill Online, Printable, Fillable, Blank Form 150: SBE CERTIFICATION Application Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 150: SBE CERTIFICATION Application

On average this form takes 35 minutes to complete

The Form 150: SBE CERTIFICATION Application form is 2 pages long and contains:

  • 3 signatures
  • 32 check-boxes
  • 114 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Payment Method: Check Money Order (payable to SBE) American Express MasterCard Visa Total: $_____________
Credit Card #___________________________________________________________ Exp. Date___________ Security Code^____________
Name on Card (if different)___________________________Billing Address (if different)____________________________________________
^ 3 digits in signature strip on back of card to the right of the (partial) card number (for Amex, it is 4 non-raised digits on the front).
SBE CERTIFICATION Application
SOCIETY OF
BROADCAST ENGINEERS
9102 North Meridian Street, Suite
150
Indianapolis, IN 46260
Phone: (317) 846-9000
Fax: (317) 846-9120
STUDENT FEE: deduct $57 from non-member fee
Non-Member fee includes optional membership in SBE through March 31 of the following year (See back for more information).
Information provided in this application will be used to determine eligibility.
Mr. Mrs. Ms. (optional)
____________________________________________________________________ (________) ___________________
Last Name First MI Primary Phone
____________________________________________________________________ (________) ___________________
Mailing Address Secondary Phone
____________________________________________________________________ (________) ___________________
City State Zip Code Fax Number
____________________________________________________________________ _____________________________
Place of Employment Date Employed Date of Birth (MM/DD/YY) optional
_______________________________ ________________________________ _____________________________
Current Job Title Type of Facility E-mail Address
______________________________________________________________________________________________________
Description of Duties
Total years of responsible Engineering Experience: _________ Radio TV Other (check all that apply)
EXPERIENCE RECORD
List in chronological order, beginning with the most recent, all formal experience in Broadcast Engineering or related employment. Indicate field(s)
of specialization under “Position.” Please do not limit yourself to the spaces below. The more details you give us about your background the easier
it will be for us to correctly judge your application. ATTACH A BRIEF DESCRIPTION OF JOB DUTIES.
From
Mo Yr
To
Mo Yr
Company Name and Location
Position or Title
Immediate
Supervisor/Contact #
EDUCATION
Transcript MUST accompany application if substituting education for part of the experience requirement, and if applying for Student Membership.
From
Mo Yr
To
Mo Yr
College, University
or Technical Institute
Credits or
Yrs Compl
Degree
ADDITIONAL INFORMATION REQUESTED ON REVERSE SIDE
NATIONAL CERTIFICATION COMMITTEE ACTION ADMISSIONS COMMITTEE ACTION
Approved Disapproved Date: ___________________ Approved Disapproved Grade: _____________________
Senior Essay Question # _____________________________ Signature: ___________________________ Date: ____________
Signature: _________________________________________
B
I wish to take the following exam(s) during the ______________exam session:
Certified Broadcast Radio Engineer (CBRE) Certified Broadcast Television Engineer (CBTE)
Certified Audio Engineer (CEA) Certified Video Engineer (CEV)
MEMBER FEE*: $73 NON-MEMBER FEE: $158 Non-MemberPlus: $248
I wish to take the following exam(s) during the ______________ exam session:
Certified Senior Radio Engineer (CSRE) Certified Senior Television Engineer (CSTE)
MEMBER FEE*: $98 NON-MEMBER FEE: $183 Non-MemberPlus: $273
click to sign
signature
click to edit
click to sign
signature
click to edit
REFERENCES
Three required. One MUST have supervised your work.
Name
Company Name and Location
Position or Title
Phone
PROFESSIONAL SOCIETIES
Name
Year Joined
Member Grade Attained
Offices Held
OTHER PROFESSIONAL LICENSES OR CERTIFICATES
SPECIAL ACHIEVEMENTS
List awards, patents, books, articles, short courses, seminars related to broadcast-communications technology, etc.
If you are applying for Certification by Examination, the Certification Chairman of your local chapter should be notified. The
closest SBE Chapter is: __________________________________________________________________________________
Upon certification, please notify my employer: No Yes If yes, complete name, title and address below:
______________________________________________________________________________________________________
EMPLOYER NAME TITLE COMPANY
______________________________________________________________________________________________________
ADDRESS CITY STATE ZIP
I have read and understand the requirements of the SBE Certification Program and certify that all information submitted is
accurate. If approved, I agree to abide by the Society of Broadcast Engineers Canons of Ethics (available at www.sbe.org).
________________________________ ______________________________________________________________
Date Signature (in ink)
RETAIN A COPY OF YOUR APPLICATION!
NOTE: If you maintain SBE membership throughout your certification period (5 years), you will receive a 10% discount on recertification.
B
SBE MEMBERSHIP: YES, I wish to take advantage of the optional SBE membership included in the
non-member certification fee. I am already an SBE Member, #___________ Decline SBE Membership
If accepting, select level of membership: Regular Member Associate Member Reinstatement (former #______)
Student Member – Must provide contact information for faculty advisor, dean, department chair, registrar, etc., for SBE to use to
verify your student status: Name ___________________________________________ Title __________________________
E-mail ________________________________________________________________ Phone_(______) ________________
If accepted, please enroll me in Local Chapter #________ Location: _____________________________________________
Sponsor’s Name/Who introduced you to SBE? (optional):______________________________________________________
SBE dues are not deductible as a charitable contribution for federal income tax purposes, but may be deductible as a business expense.
SBE estimates that 1% of your dues are not deductible because of SBE’s lobbying activities on behalf of its members.
Have you ever been convicted of a felony? Yes No If yes, describe in full. (Use additional paper if necessary.)
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 150: SBE CERTIFICATION Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document