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6010 Medical Gas Installer / Brazer Examination Request Form

*  The Medical Gas Installer 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 32-hours of instruction per the ASSE Series 6000 Standard 6010? 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**

*Please Check One: Med Gas Written/Braze Med Gas Written Only
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.