6050 Medical Gas Instructor Recertification Examination Request Form

(This request form is for the 2021 instructor written recertification only).

The fee per examination is $49.00 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 $150.00 will be applied.

Please complete all information below: (*Required Fields*)
*Name of Instructor:
*Examination Location:
*Examination Address:
*City, State, Zip:
*Contact Person:
Phone Number:
*E-mail Results To:
*Date of Examination:
Time:
*Number of Examinees:
* 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:
*Please Check One: