Medical Gas Maintenance Recertification Exam Request

Please complete all information below: (*Required Fields*)
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.
*Name:
*S.S. # / NITC ID #/ UA ID #:
*Address:
*City:
*State:
*Zip:
Phone #:
Local No (if applicable):
E-mail:
*Please Check One:
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 (888) 234-6834. If payment is made by phone the form must be received via fax or email maintenance@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: