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6040 Medical Gas Systems Maintenance Personnel Examination Request Form

* The Medical Gas Systems Maintenance Course must be taught by a certified 6050 Medical gas Instructor.

* The fee per examination is $116.00 dollars. 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.

*This request form must be submitted no later than (3) weeks prior to
examination date. Please e-mail to maintenance@nationalitc.com.

*All exams will be administered via computer.

*A minimum of 10 examinees is required for an examination. If there are less than 10 examinees,
a processing fee of $150.00 will be applied.

*It is the requesting entity’s responsiblity to notify each applicant.


Please complete all information below: (** 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.