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The American Fisheries Society APPLICATION FOR PROFESSIONAL CERTIFICATION For applicants who completed their B.S./B.A. (or equivalent) degree on or after July 1, 2002 All applications must be submitted electronically via email with the applicants name and “Certification Application” in the subject line to Gail Goldberg, [email protected] Mail payment and signed copy of declaration page to: AMERICAN FISHERIES SOCIETY-CERTIFICATION 5410 Grosvenor Lane, Suite 110 Bethesda, Maryland 20814-2199 If you have any questions, please contact (301) 897-8616X201 or [email protected] . Thank you for participating in the AFS Professional Certification Program! Name: Justin Eli Powers Title: Trout Habitat Biologist Mailing Address: 123 MC 6025 Yellville, AR 72687 Phone: 870 656-3355 Fax: 870 425-6596 Email: [email protected] Name, as it should appear in your certificate: Eli Powers APPLICATION FOR: ____X____ Certified Fisheries Professional (FP-C) (First time applicants for Certified Fisheries Professional designation) _________Certified Fisheries Professional (FP-C ESTABLISHED) (First time applicants for Certified Fisheries Professional designation, applying as established fisheries professionals) _________Certified Fisheries Professional, Renewing (FP-C- RENEW) (Previously certified Fisheries Professional applicants, renewing professional certification) _________Certified Fisheries Professional (FP-A to FP-C) (Previously certified Associate Fisheries Professionals upgrading to Certified Fisheries Professional designation) _________Associate Fisheries Professional (FP-A) (First time applicants for Associate Fisheries Professional designation) ________Will accept certification as either Certified Fisheries Professional or Associate Fisheries Professional, as granted by the Board after review. (First time applicants uncertain as to category because of professional and qualifying experience) (EITHER) FP-C – Email an Application for Certification (all sections), a completed Professional Development Form and attach scanned official academic transcripts. Mail the Application fee in U.S. funds. Fee is $100 for AFS members and $200 for nonmembers.

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Page 1: Cert_App_2000_02 · Web viewMaintaining all equipment for both the Trout Management Program and the warm water fisheries District 2. I maintained and repaired all equipment on a …

The American Fisheries SocietyAPPLICATION FOR PROFESSIONAL CERTIFICATION

For applicants who completed their B.S./B.A. (or equivalent) degree on or after July 1, 2002

All applications must be submitted electronically via email with the applicants name and “Certification Application” in the subject line to Gail Goldberg, [email protected]

Mail payment and signed copy of declaration page to: AMERICAN FISHERIES SOCIETY-CERTIFICATION

5410 Grosvenor Lane, Suite 110Bethesda, Maryland 20814-2199

If you have any questions, please contact (301) 897-8616X201 or [email protected] you for participating in the AFS Professional Certification Program!

Name: Justin Eli PowersTitle: Trout Habitat BiologistMailing Address: 123 MC 6025 Yellville, AR 72687

Phone: 870 656-3355 Fax: 870 425-6596Email: [email protected], as it should appear in your certificate: Eli Powers

APPLICATION FOR: ____X____ Certified Fisheries Professional (FP-C) (First time applicants for Certified Fisheries Professional designation)

_________Certified Fisheries Professional (FP-C ESTABLISHED)

(First time applicants for Certified Fisheries Professional designation, applying as established fisheries professionals)

_________Certified Fisheries Professional, Renewing (FP-C-RENEW)

(Previously certified Fisheries Professional applicants, renewing professional certification)

_________Certified Fisheries Professional (FP-A to FP-C)(Previously certified Associate Fisheries Professionals upgrading to Certified Fisheries Professional designation)

_________Associate Fisheries Professional (FP-A)(First time applicants for Associate Fisheries Professional designation)

________Will accept certification as either Certified Fisheries

Professional or Associate Fisheries Professional, as granted by the Board after review. (First time applicants uncertain as to category because of professional and qualifying experience) (EITHER)

FP-C – Email an Application for Certification (all sections), a completed Professional Development Form and attach scanned official academic transcripts.

Mail the Application fee in U.S. funds. Fee is $100 for AFS members and $200 for nonmembers.

FP-C ESTABLISHED – Email an Application for Certification (omit section II), a completed Professional Development Form and attach scanned documentation of the highest degree you have earned.

Mail the Application fee in U.S. funds. Fee is $100 for AFS members and $200 for nonmembers.

FP-C RENEW – Email this page, and a completed Professional Development Form. Mail the Application fee in U.S. funds. Fee is $50 for AFS members and $100 for nonmembers. If an applicant does not renew by December 31st of the year their certification expires, there is a penalty of $10 per year since the certification lapsed.

FP-A to FP-C – Email an Application for Certification (omit section II), and a completed Professional Development Form. Please document any degree obtained after original FP-A Application.

Mail the Application fee in U.S. funds. Fee is $50 for AFS members and $100 for nonmembers.

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APPLICATION FOR PROFESSIONAL CERTIFICATION

Section I: EDUCATION

Institutions Dates Attended

Degree* Date Degree

Awarded

Majors Minors

University of AR Community College at Batesville(UACCB)

Fall 2000To Spring2002

50 hrs obtained toward degree

Arkansas Tech University (ATU)

Fall 2002To Spring2005

BS in Fisheries and Wildlife Science

May 14, 2005

Fisheries and Wildlife Science

Title of Master's Thesis:

Title of Doctoral Dissertation:

*If degree not obtained, indicate number of hours toward degree. ______50_________

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APPLICATION FOR PROFESSIONAL CERTIFICATIONSection II: MINIMUM COURSEWORK REQUIREMENTS

This form is valid for individuals who obtained their B.A. /B.S (or equivalent) on or after July 1, 2002. Please include only the minimum number of hours needed for each area. Read the Program Description and FAQ for descriptions of required coursework, available at www.fisheries.org. Course grades must be ‘C-’ or better to be acceptable, no pass/fail courses. Attach a scan of official transcripts (must include legend). If coursework is deficient in any area, request the Guidelines for Satisfying Coursework Deficiencies from AFS headquarters. Individuals applying as ‘FP-C Established’ do not complete this section.

Subject Area School Course Number

Course Title Semester Hrs1

A. Fisheries and Aquatic Sciences. Four (4) courses, Two of which must be directly related to fisheries sciences and at least one must cover principles of fisheries science and management.

ATUATUATUATU

FW3084FW3204FW4043FW4083

IchthyologyAquacultureFisheries TechniquesPrinciples of Fisheries Management

4433

B. Other Biological Sciences courses, which when added to the above courses must total 30 semester hours.

UACCBUACCBATUATU

Biol1114Biol1124FW3114Biol1134

Principles/BiologyPrinciples/ZoologyPrinciples of EcologyPrinciples of Botany

4444

TOTAL of A + B 30

C. Physical Sciences courses. Must total 15 semester hours.

ATUATUATUATU

Chem1114Chem2204Phys1114Biol4024

Survey of ChemistryOrganic Phys ChemistryApplied PhysicsLimnology

4444

TOTAL of C 16

D. Mathematics and Statistics courses, which must include one calculus and one statistic or two statistics courses.Must total 6 semester hours.

ATUATU

Psy2053Math2243

Statistics/Behavioral SciCalculus-Business/Econ

33

TOTAL of D 6

E. Communications courses. Must total 9 semester hours.

UACCBUACCBUACCB

Sph2003Eng1013Eng1023

Public SpeakingComposition IComposition II

333

TOTAL of E 9

F. Human Dimensions courses. Must total 6 semester hours.

ATUATU

Fw3053RP3053

Fisheries/Wildlife ADMNat Resource/MGT/Plan

33

Total of F 6

1Semester hours = quarter hours x 2/3

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APPLICATION FOR PROFESSIONAL CERTIFICATION

Section III: QUALIFYING FULL-TIME EXPERIENCE(In chronological order, current employment first)

Employer: Arkansas Game and Fish Commission________________

Address: 201 East Fifth Street, Mountain Home, AR 72653__________________________

Period in this position: From: ________18, July, 2005_____To: ____15, November, 2008___ (Day, Month, Year) (Day, Month, Year)

Position title: Natural Resource Program Technician_______________________________________

Description of specific duties and responsibilities as a fisheries professional (Specifically list how the job met the criteria for qualifying experience as described in the Program Description, available at www.fisheries.org/afs/certification.html):

As a Natural Resources Program Technician for the Trout Management Program (TMP), I was tasked with the following duties: Conducting angler creel surveys on the White/Norfork Rivers, Dry Run Creek, Big

Spring, and Amon’s Lake, and entering the data collected into an Access database to be used in reports produced by the TMP for fisheries management purposes in Arkansas trout waters.

Assisting with and conducting biological sampling, including; electrofishing, rotenone, seining, and kick netting. I often led crews during electrofishing samples, where I would operate the boat and supervise the activities during the sample. I was responsible for gathering the data that was to be used in management applications, and in graduate and doctoral research projects.

I assisted other fisheries personnel with various projects when needed. Occasionally, I helped the Net Pen facility on Bull Shoals Lake with daily activities such as: feeding, sampling, and harvesting fish, distributing feed to private net pen operations, and repairing broken or impaired equipment. I also assisted the Spring River Trout Hatchery with clean-up after catastrophic floods and weather events. I assisted during the trial-run of the Northern Snakehead Eradication efforts, where I electrofished numerous bodies of water in search of northern snakeheads.

I performed hundreds of gut analysis on brown trout collected during annual electrofishing samples. I preserved, rinsed, sorted, and identified all of the contents of each gut. This data was useful in annual TMP reports.

Collecting physical and chemical data for the bodies of water of interest. I often collected such variables as: temperature, dissolved oxygen, pH, conductivity, hardness, ORP, and numerous habitat variables.

Maintaining all equipment for both the Trout Management Program and the warm water fisheries District 2. I maintained and repaired all equipment on a regular and as-needed basis. The equipment that I was responsible for was all of the electrofishing boats and accompanying gear, plus all other sampling equipment utilized during day to day operations. Good data comes from properly maintained equipment and properly used equipment. Very Critical! Proper maintenance is also directly related to the safety of me and all other workers around me. I am proud to say that no injuries were reported due to maintenance issues during the time I held the technician position.

Maintaining the Invoice Database for the TMP. I was responsible for invoices that were paid from the TMP annual budget; I would code and submit all invoices from vendors, and also keep track of the annual TMP budget that way we could operate more efficiently and effectively on a strict budget.

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I assisted with numerous public events. I helped run a couple of public meetings pertaining to trout fishing in Arkansas. I assisted with judging a regional science fair on several occasions, where I judged science projects pertaining to aquatic sciences. I manned a table at several public outdoor events, where I answered questions from the public.

I also attended several meetings and courses pertaining to fisheries science, and professional development. I attended the Arkansas American Fisheries Society meeting on an annual basis. I also attended several professional development courses provided by our agency and by state universities, for example: Franklin Covey Seven Habits Course, Fish Diseases Workshop, Conflict Resolution, Stream and Riparian Corridor Restoration Workshop, Principles and Techniques of Electrofishing, etc…

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APPLICATION FOR PROFESSIONAL CERTIFICATION

Section III: QUALIFYING FULL-TIME EXPERIENCE(In chronological order, current employment first)

Employer: Arkansas Game and Fish Commission_______________________________________

Address: 201 East Fifth Street, Mountain Home, AR 72653________________________________

Period in this position: From: _16, November, 2008_______To: _______Present Day_________ (Day, Month, Year) (Day, Month, Year)

Position title: Trout Habitat Biologist__________________________________________________

Description of specific duties and responsibilities as a fisheries professional

As a Biologist Specialist for the Trout Habitat Program (THP), I am tasked with the following duties: Conducting stream bank (Riparian) renovation and restoration projects on the Trout

Tailwaters and the main stems of their headwaters. Our program is responsible for conducting these projects from start to finish. I assist with surveying the project area before construction, developing plans, drawing up plans to be used in acquiring needed permits, obtaining materials for the project, construction of the project, and post project maintenance.

Conducting in-stream habitat work in the Trout Tailwaters of the state to promote better fishing opportunities for the anglers, and to provide better feeding and refuge areas for the trout and organisms in the stream. I am currently working on a broad scale habitat assessment process utilizing side-imaging technology. This technology allows us to quantify the current habitat that is available, and also allows us to track changes to the habitat over time. In conjunction with the side-imaging technology, I also utilize basic stream habitat survey techniques to obtain physical and hydrological data about the stream.

Assisting river and stream bank landowners with erosion and drainage issues with their properties. I help them with developing plans to correct the problems they have with their stream bank. I also help them with submitting the proper paperwork and permits in order to obtain permission to work on their project. By assisting these landowners, we can help lower the amount of sedimentation into our trout streams.

Performing presentations about our projects to various user groups. Attending and completing numerous upper level stream restoration courses from

such names as Rosgen, Newberry, and Derrick. These courses have helped me in understanding the dynamics of the river and stream systems that we work on every day.

Assisting other agencies and organizations with various stream restoration projects throughout the state.

Assisting the Trout Management Program and other Fisheries Districts of the state with fish sampling.

Assisting with educational classes for various user groups in our state. I often teach about macro-invertebrates, stream health, restoration projects, and electrofishing.

Maintaining the Invoice Database for the THP. I am responsible for all invoices paid through the THP; I code and submit all invoices from vendors, and also keep track of the annual THP budget that way we can operate more efficiently and effectively on a strict budget.

Supervision of one full-time technician and one extra-labor technician for the THP.

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APPLICATION FOR PROFESSIONAL CERTIFICATION

Section IV: QUALIFYING, EXPERIENCE RELATED,PROFESSIONAL COMMUNICATIONS

Publications: Give complete citations -- author(s), year, title of paper, publication volume and number and pages. Cite no more than five of your most recent or significant publications.

Powers, J. E., 2012. Protecting Your Investment: A Landowner’s Guide to Understanding Riparian Areas

Administrative reports: Give complete citations -- author(s), year, title, pages. Cite no more than five of your most recent or significant reports.

Powers, J. E., 2013. AGFC Streambank Protection and Stabilization EPA 319(h) Project # 11-1500Burnley, T., and Powers, J. E., 2013. Trout Habitat Program Annual ReportBurnley, T., and Powers, J. E., 2012. Trout Habitat Program Annual ReportBurnley, T., and Powers, J. E., 2011. Trout Habitat Program Annual ReportBurnley, T., and Powers, J. E., 2010. Trout Habitat Program Annual Report

Oral reports or presentations: Give year and title, and identify the audience. Cite no more than five of your most recent or significant presentations.

2/2/2011: “Skinny Water Project: Little Missouri River and the Beaver Tailwater Project”Presented to fisheries professionals and students at the Arkansas AFS Chapter annual meeting.

9/19/2011: “Beaver Tailwater Project”Presented to public attendees at the Beaver Tailwater Management Plan Meeting.

10/13/2013: “Sheid/Blossom Project”(EPA 319 Grant on White River/Kings River)

Presented to Fisheries Professionals at the annual MOARK meeting, a joint meeting between Arkansas Game and Fish Commission and Missouri Dept of Conservation.

1/23/2013: “Beaver Tailwater Improvement Project”Poster displayed to fisheries professionals and students at the Arkansas AFS Chapter annual meeting.

11/6/2013: “Dr. Depth Side Imaging and Bottom Mapping Software”Presented to fisheries professionals at AGFC’s Fisheries Division Wide annual staff meeting

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APPLICATION FOR PROFESSIONAL CERTIFICATION

Section V: PROFESSIONAL INTERESTS AND GOALS

Affiliations in AFS (i.e., Division, Chapter, Section, Committee):AR AFS Chapter Raffle/Silent Auction Committee Chair (2013 – Present)AR AFS Chapter student member (2003 – 2005)AR AFS Chapter professional member (2005 – Present)

Affiliations in other professional, scientific, or honorary societies:AGFC Trout Team Committee MemberServices to AFS and other professional or scientific societies:Assisted Raffle/Silent Auction Chair at the National AFS meeting in September 2013 in Little Rock AR, where I collected items to be used in the Silent Auction. I also assisted the committee chair with setting up the silent auction tables, attending the tables while the auction was open, collecting bid sheets and money upon the auctions close, and delivering the items to the appropriate auction winners.

I currently am responsible for all aspects of the Raffle/Silent Auction Committee. I collect goods and services from vendors, I create bid sheets for each item collected, I set up the silent auction tables to display the goods and services provided, I collect money upon the closure of the event, I send thank you letters to all who supported our event, and I provide updates in the Lateral Line, our Chapter’s quarterly newsletter.

What are your goals as a fisheries professional?My goal is to provide my skills and knowledge, as a fisheries professional, to the stakeholders of Arkansas’ fisheries and aquatic resources, in order to provide them with the same opportunities I had growing up. I was fortunate to have the opportunity to enjoy the bounty of Arkansas’ outdoors, and I feel that it is my duty to maintain the resource that has provided me with such pleasure. Streams are very important to me and with the constant changes in land management practices and steady urbanization; I would like to do my part in conserving and restoring impaired streams for all future stakeholders.

Section VI: FISHERIES PROFESSIONAL CODE OF PRACTICES

DECLARATION: As a fisheries professional, I will strive to conform to the American Fisheries Society Standards of Professional Conduct and support and promote the North American Fisheries Policy. I further attest that the information provided in this application, together with all attached documents is true to the best of my knowledge. If any part of the information provided herein is false, I understand that my certification will be revoked.

Date Submitted:___12/16/14_________________________

Applicants Name: _____Justin Eli Powers______________

Applicant Signature: ____________ _______

MAIL Application fee AND this page to:

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AMERICAN FISHERIES SOCIETY-CERTIFICATION5410 Grosvenor Lane, Suite 110Bethesda, Maryland 20814-2199

PROFESSIONAL DEVELOPMENT ACTIVITY FORM

The Professional Development Activity Form reflects professional development quality points (PDQPs) as listed on the following pages.

PDQPs: 1/1/2012 Beginning Documentation Date

12/31/2014 Ending Documentation Date

___20___ Category I & II

___14___ Category III

________ Category IV

________ Category V

___38___ TOTAL

FP-C – Professional Development Activity Form indicates a summary of Professional Development Quality Points for the previous 2 years. A total of 30 PDQPs over the previous 2 years are required. A minimum of 10 of these points, and a maximum of 20, must fall under categories I & II; a minimum of 10 of these points, and a maximum of 20 points, must fall under categories III, IV, and V.

FP-C ESTABLISHED – Professional Development Activity Form indicates a summary of Professional Development Quality Points. Applicants may choose to document points over a previous 2 year or 5 year time frame. For the 5 year time frame, a total of 100 PDQPs are required; a minimum of 35 of these points, and a maximum of 60, must fall under categories I & II; a maximum of 35 points may fall under each of the remaining categories (III, IV, and V). For the 2 year time frame 40 PDQPs are required; a minimum of 14 of these points, and a maximum of 24 must fall under categories I and II; a minimum of 16 points must fall under categories III IV and V, and a maximum of 26 points may fall under two categories of the ‘III, IV, and V’ group.

FP-C RENEW – Professional Development Activity Form indicates a summary of Professional Development Quality Points for the previous 5 years. A total of 100 points over the previous 5 years are required. A minimum of 35 of these points, and a maximum of 60, must fall under categories I & II. A maximum of 35 points may fall under each of the remaining categories (III, IV, and V).

FP-A to FP-C – Professional Development Activity Form indicates a summary of Professional Development Quality Points for the previous 2 years. A total of 30 PDQPs over the previous 2 years are required. A minimum of 10 of these points, and a maximum of 20, must fall under categories I & II; a minimum of 10 of these points, and a maximum of 20 points, must fall under categories III, IV, and V.

FP-A – First time FP-A applicants do not complete this form.

EITHER – Professional Development Activity Form indicates a summary of Professional Development Quality Points for the previous 2 years. A total of 30 PDQPs over the previous 2 years are required. A minimum of 10 of these points, and a maximum of 20, must fall under categories I & II; a minimum of 10 of these points, and a maximum of 20 points, must fall under categories III, IV, and V.

AMERICAN FISHERIES SOCIETYwww.fisheries.org

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PROFESSIONAL DEVELOPMENT ACTIVITY FORM

Category I: Continuing education-fisheries

Includes subjects directly related to fisheries science or management. Examples include fisheries management, habitat management, fisheries economics, fish diseases, aquaculture or fish culture, fisheries policy and law, aquatic ecology, etc.

Activities PDQPs

Participation in courses or training programs sponsored or conducted by commercial organizations, professional organizations/agencies, employers, or universities

0.5 per hour of instruction

Attendance at annual or semiannual meetings or special conferences of professional societies, educational organizations, etc.

0.5 per hour of participation

Attendance at in-house meetings of employer involving education on new techniques or developments in the profession

0.5 per hour of participation

Completion of self-instruction audiovisuals 0.5 per hour of instruction

Attendance at seminars conducted by experts in the subject matter 0.5 per hour of instruction

Please record activities in the chart included below (you may include as many pages as needed).

Category IActivity Description

Provider Date PDQPs

Stream Restoration: Design Workshop (Dr. Robert Newberry)

Canadian Rivers Institute

9/30/14 – 10/2/14

12

AR AFS Annual Fisheries Chapter Meeting AR AFS 2/26/14 – 2/28/14

8

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PROFESSIONAL DEVELOPMENT ACTIVITY FORM

Category II: Continuing education – nonfisheries

Includes subjects that are not primarily fisheries oriented but are professionally enriching to the individual. Examples include computer science and statistics, managerial and leadership skills, public speaking, problem-solving, public relations, marketing, planning, and other related natural resource disciplines such as forestry, wildlife, etc.

Activities PDQPs

Participation in courses or training programs sponsored or conducted by commercial organizations, professional organizations/agencies, employers, or universities

0.5 per hour of instruction

Attendance at annual or semiannual meetings or special conferences of professional societies, educational organizations, etc.

0.5 per hour of participation

Attendance at in-house meetings of employer involving education on new techniques or developments in the profession

0.5 per hour of participation

Completion of self-instruction audiovisuals 0.5 per hour of instruction

Attendance at seminars conducted by experts in the subject matter 0.5 per hour of instruction

Please record activities in the chart included below (you may include as many pages as needed).

Category IIActivity Description

Provider Date PDQPs

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PROFESSIONAL DEVELOPMENT ACTIVITY FORM

Category III: Oral communications in fisheries and nonfisheries subjects

Includes the development, preparation, and presentation of activities such as those described in categories II and I. Context is any public meeting that is open to the general public or a select group of invited participants. For fisheries subjects, the audience need not be fisheries professionals. For nonfisheries subjects, the audience must be fisheries professionals. Multiple presentations of the same or similar subject matter can only be credited once during a certification renewal period.

Category III: Oral communications in fisheries and nonfisheries subjects

Activities PDQPs

Author/coauthor of an oral or poster presentation at a professional meeting

7

Author/coauthor of an oral or poster presentation to a nonprofessional audience

7

Organizer/instructor of a short course or workshop 20

Instructor of a quarter- or semester-length course 10 points per creditmaximum 30

Author/producer of self-instruction audiovisuals in fisheries 20

Please record activities in the chart included below (you may include as many pages as needed). Must include titles for presentations, courses, workshops, or audiovisuals

Category IIIActivity Description

Provider Date PDQPs

“Dr. Depth Side Imaging and Bottom Mapping Software” Oral Presentation

AGFC Fisheries Division Staff meeting

11/6/2013 7

“Sheid/Blossom Project”(EPA 319 Grant on White River/Kings River)

MOARK annual meeting

10/13/2013 7

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PROFESSIONAL DEVELOPMENT ACTIVITY FORM

Category IV: Written communicationsDeveloping, writing, editing, reviewing, and publishing fisheries-oriented materials. The written material need not be published, but it must be readily available to professional and nonprofessional audiences.

Activities PDQPs

Author/coauthor of peer-reviewed article or book chapter 15

Author/coauthor of a book/monograph 30

Editor/coeditor of a book/monograph 15

Author/coauthor of non-peer-reviewed article in a magazine, brochure, newspaper, etc.

7

Author/coauthor of an agency publication or report 10

Reviewer or editor of an article that has been submitted for publication 3

Book reviewer for a professional publication 5

Please record activities in the chart included below (you may include as many pages as needed). Please include citations for all publications.

Category IV Activity Description

Provider Date PDQPs

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PROFESSIONAL DEVELOPMENT ACTIVITY FORM

Category V: ServiceInvolves membership and active participation in fisheries or aquatic professional societies and organizations, and community service that draws on the individual’s professional expertise in fisheries. Community service may include contributions of professional expertise to civic groups, environmental organizations, government, etc. Points are given for each year served in multiple-year appointments.

Activities PDQPs

Holding the highest office in an organization (including subdivisions), (e.g., president, director, chair, journal editor, etc.)

15

Holding the other offices in an organization (including subdivisions), (e.g., secretary, treasurer, associate editor, newsletter editor, Committee chair, etc.)

10

Committee Member 4

Mentor in the Hutton Junior Fisheries Biology Program 10

Please record activities in the chart included below (you may include as many pages as needed).

Category V Activity Description

Provider Date PDQPs

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PROFESSIONAL DEVELOPMENT ACTIVITY FORM

DECLARATION: Having completed the Professional Development Activity Form, I hereby apply for professional status as a Certified Fisheries Professional. I attest that to the best of my knowledge the information contained in this application and any attached material is complete and true. If any part of the information provided herein is false, I understand that my certification will be revoked. As a fisheries professional, I will strive to conform to the American Fisheries Society Standards of Professional Conduct, and support and promote the North American Fisheries Policy.

Date Submitted: _12/16/14_

Applicant Signature: _______________ __________________(Name typed here shall serve as signature. Not valid unless signed. If not signed, please explain in an attached letter.)

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PROFESSIONAL DEVELOPMENT ACTIVITY FORMPlease use this chart as extra space for all professional development categories.

Category _______ Activity Description

Provider Date PDQPs

If you have questions or comments about the AFS Professional Certification Program, please contact Gail Goldberg at [email protected] or at 301-897-8616 x 201.