Medical Gas Generalist Registration Form For Online Test

I have taken a minimum of (4) hours training to the current NFPA edition. Please include a copy of your “certificate of completion” or verification with this registration form.
Please complete all information below: (Required Fields)

*First & Last Name:

*S.S. # / NITC ID #/ UA ID #:

*Address:

*City:

*State:

*Zip:

Phone #:

Local No (if applicable):

E-mail:

The fee is $ 60.00 per re-certification examination. Please make check or money order payable to NITC. Visa, MC or Amex are also accepted. Note: In some cases , payment is provided by the training agency or employer. Method of Payment must be included with form or call to pay by phone at (877) 457 - 6482. If payment is made by phone the form must be received via fax or email medgascerts@nationalitc.com beforehand.
Once payment has been received, you will receive an email from NITC within 2 to 3 business days with your online login information.
Signature of Applicant:

Date: