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6005 Medical Gas Generalist Examination Request Form

* The Medical Gas Generalist Course must be taught by a certified 6050 Medical Gas Instructor
* The fee per examination is $116.00. This must be prepaid.  Contact NITC to provide credit card payment information by phone at (877) 457-6482. For NITC No-Show, Cancellation and Refund Policy refer to the Candidate Bulletin.
The request form and completed application(s) must be submitted no later than three (3) weeks prior to examination date.
* A minimum of 10 applicants is required for an examination. If there are less than 10 applicants, a processing fee of $150.00 (computed based) will be applied.
* It is the requesting entity’s responsibility to notify each applicant.

Please fill in the information below:(** Required Fields **)

Examination Request:  NFPA 2018

Have all applicants completed 24-hours of instruction per the ASSE Series 6000 Standard 6005? Yes  No
Will any additional examinations be given along with this examination? Yes  No
How would you like the exam to be provided? Computer BasedPaper & Pencil (10 or more)
Need NITC to find a proctor:YesNo
Test Packets Will Not Be Sent To PO BOXES

Will the proctor waive his/her proctoring fees? YesNo
Please type all the information (completely) for each applicant as you would like it to appear on their certification.
**Required Fields**

You can upload pdf application files along with this request by choosing to upload a file below.  Examination Request will be denied if completed application are not submitted.