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

* The fee per examination is $116.00. This must be prepaid. Please make check or money order payable
to NITC. Visa, Master Card or American Express is also accepted. The method of payment must be attached at the time of submission or 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 datePlease e-mail to medgascerts@nationalitc.com.

* 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.

Examination Request:  NFPA 2018

Name of Instructor:

NITC ID # / UA ID:

Examination Location

Examination Address

City

State

Zip

Contact Persons

Phone #

E-mail Results To

Date of Examination

Time

Number of Examinees

*Have all applicants completed 40-hours of instruction per the ASSE Series 6000 Standard 6050? Yes  No

*Will any additional examinations be given along with this examinationYes  No

*How would you like the exam to be provided? Computer BasedPaper & Pencil

*Need NITC to find a proctor:YesNo

Please print or type all the information (completely) for each applicant as you would like it to appear on their certification.
**Required Fields**