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

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The Medical Gas Instructor Course must be taught by a certified 6050 Medical Gas Instructor.
The fee per examination is $130.00. 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 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 examinees is required for an examination. If there are less than 10 examinees, a processing fee of $175.00 will be applied.
It is the requesting entity’s responsibility to notify each applicant.
Please complete all information below: (*Required Fields*)
*Examination Request:
*Examination Location:
*Name of Instructor:
NITC ID #/UA ID #:
*Examination Address:
*City, State, Zip:
*Contact Person:
Phone Number:
*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?:
* Will any additional examinations be given along with this examination?:
*Need NITC to find a proctor:

Exam materials will be emailed to the Proctor
Proctor’s Name:
Address:
City, State, Zip:
Cell Phone Number:
Email:
Will the proctor waive his/her proctoring fees?:

Please print or type all the information (completely) for each applicant as you would like it to appear on their certification.
*Name:
*S.S. # / NITC ID #/ UA ID #:
*Address:
*City:
*State:
*Zip:
Phone #:
Local No (if applicable):
E-mail:

Document
Attach all documents that apply:
E-mail to send confirmation to: