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Title 24 Compliance

 

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.

This request form and completed application(s) must be submitted no later than three (3) weeks prior to examination date. Please e-mail to medgascerts@nationalitc.com.

All exams will be administered via computer.

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

It is the requesting entity’s responsibility to notify each applicant

I will be taking this exam at a Prometric Test Center.:
 
I have a minimum of ten (10) years of documented practical experience in the installation of plumbing or mechanical piping systems, including a minimum of two (2) years of documented experience in the installation or medical gas and vacuum systems:
I have at least two (2) years documented practical teaching experience:
I hold a current NITC Medical Gas Systems Installer certification in compliance with ASSE Standard 6010:
I will have completed the required 40 hour training course prior to my test date. (Course instruction must be conducted by a Medical Gas System Instructor certified to a ASSE 6050)
I have read the Candidate Information Bulletin for NITC Medical Gas Instructor Examination
I am requesting the examination to the NFPA 99-2021 addition
Add For Individuals requesting to take an examination at a Prometric Center, there will be an additional sixty-dollar ($60.00) processing fee.

Personal

First Name:
M.I:
Last Name:
SSN #:
Street Address:
City:
State:
Zip:
Email Address:
Cell/Other Phone:
Training Course Location:
Training Course Date:
Name of Instructor:
Local Union # (If Applicable):
Applicants NITC ID # / UA ID # (If Applicable):

Experience

List your present or most recent employer first. Attach any documentation you have that would prove that you a minimum of ten (10) years of documented experience in the installation of piping systems or a minimum of two (2) years of documented experience in the installation of medical gas and vacuum systems, and a minimum of two (2) years documented practical teaching experience. Acceptable documentation: letters from employers, employment history, certification records, state license(s) and any other employment records. (Phone numbers are required for verification.)
Employer Name #1:
City:
Phone:
From Month/Year:
To Month/Year:
Employer Name #2:
City:
Phone:
From Month/Year:
To Month/Year:
I do solemnly swear or affirm that the above statements are true. I further realize that falsification of these statements shall be cause for disqualification. As a holder of a NITC Certification I shall agree to the following:
• I will make no false claims about the scope of my certification(s) • I will not engage in false or misleading advertising of my NITC Certification, nor shall I utilize an NITC certification in any manner that portrays NITC unfavorably. • I will not utilize any written documents, reports, procedures, etc., with the NITC certification mark in any manner whatsoever that may be inaccurate or false. • I will notify NITC without delay of any changes in my capability to fulfill the requirements of this certification.
I understand that NITC reserves the right to suspend or revoke my certification should I violate these obligations. Should my certification be revoked, I agree to cease and desist any and all references to being the “holder” of an NITC Certification and shall return any certificates, including wallet sized photo identification cards to NITC.
I understand and agree that my examination results may be shared with the course instructor, training coordinator or training entity.
By affixing my signature to this application, I agree to abide by the rules and regulations of certification holders as set forth by the NITC Certification Committee.
Only Sign and Submit if you are Testing at a Prometric Center.
Signature of Applicant:
Date:
Attach all documents that apply: