Medical Gas Instructor Group Recertification Examination Form

 The fee per examination is $60.00 dollars. 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. 
Please complete all information below: (**Required Fields**)
Examination Location:
Examination Address:
City, State, Zip:
Contact Person:
Phone No:
Date of Examination:
Time:
Number of Examinees:
I (Name of Instructor) attest that all applicants will have completed the mandatory 4 - hour training course per the ASSE Series 6000 Standard 6050 prior to the test date (Signature of Instructor)
Name of Instructor:
Signature of Instructor:
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 No:
Email:
Will the proctor waive his/her proctoring fees?:
Please enter all information completely for each applicant . Examinees who do NOT have an email address will not be sent their exam results.
Name:
S.S. # / NITC ID #/ UA ID #:
Address:
City:
State:
Zip:
Phone #:
Local No (if applicable):
Email:

Name:
S.S. # / NITC ID #/ UA ID #:
Address:
City:
State:
Zip:
Phone #:
Local No (if applicable):
Email:

Name:
S.S. # / NITC ID #/ UA ID #:
Address:
City:
State:
Zip:
Phone #:
Local No (if applicable):
Email: