BCR Cyber Cybersecurity Technical Proficiency Activity

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Company Information

Company Name

A2LA Cert. #

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Will you be the signatory on the Remote Testing Agreement?

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Assessor #1 (Primary Contact) Information

Assessor - Primary Contact?

First Name

Last Name

Email

Phone

Role

Junior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Senior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: This role requires a CISSP and another certification from this list (2 total)):

Penetration Tester Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Please enter the license number(s) for the certificates your selected above: (For example, "CISSP #123456, CISA #7890")

___________________________________________________________________________________________

Assessor #2 Information

Please input Assessor #2's information:

First Name

Last Name

Email

Phone

Role

Junior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Senior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: This role requires a CISSP and another certification from this list (2 total)):

Penetration Tester Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Please enter the license number(s) for the certificates your selected above: (For example, "CISSP #123456, CISA #7890")

___________________________________________________________________________________________

Assessor #3 Information

Please input Assessor #3's information:

First Name

Last Name

Email

Phone

Role

Junior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Penetration Tester Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Please enter the license number(s) for the certificates your selected above: (For example, "CISSP #123456, CISA #7890")

___________________________________________________________________________________________

Do you need to add an additional assessor?

Assessor #4 Information

Please input Assessor #4's information:

First Name

Last Name

Email

Phone

Role

Junior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Penetration Tester Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Please enter the license number(s) for the certificates your selected above: (For example, "CISSP #123456, CISA #7890")

___________________________________________________________________________________________

Do you need to add an additional assessor?

Assessor #5 Information

Please input Assessor #5's information:

First Name

Last Name

Email

Phone

Role

Junior Assessor Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Penetration Tester Certification Requirement. Hold the ctrl key on your keyboard and click on each applicable certificate. (Note: Only 1 certification from the list required):

Please enter the license number(s) for the certificates your selected above: (For example, "CISSP #123456, CISA #7890")

Contact Type

Assessor Status

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