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6050 Medical Instructor Examination Request Form

*  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
* 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 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
Test Packets Will Not Be Sent To PO BOXES

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

If you would like to include any additional documentation, you can upload a pdf file along with this application below by choosing to upload a file.