Application for State of West Virginia Fire Sprinklerfitter Certification Examination

Please Note: The fee is One Hundred Eighty-Two Dollars ($182.00). This must be prepaid and is NON-REFUNDABLE. Contact NITC at (877) 457-6482 to provide credit card payment information. This exam is only available computer based and administered at PSI centers; go to http://nationalitc.com/psi-locator.cfm to locate a PSI center. An email address must be provided; you will receive an e-mail confirmation with your login information to schedule the exam date and time. A rescheduling fee of $57.00 dollars will be charged for cancelled examinations. Applicants for this examination shall have a minimum of 10,000 hours experience in the Fire Sprinkler industry.

First & Last Name

S.S. # (last six)

Address

Residence Phone

City/State

Zip

Email Address

Work Phone

Cell/Other Phone

To qualify to take this exam you must submit proof of 10,000 hours of experience in your specialty. Testimonial letters from employers are required if you do not possess a valid journeyman certificate sustaining the required experience. Testimonial letters must be on company letterhead and notarized. They must fully describe duties performed; dates employed and be accompanied with W-2 forms.

Have you taken this exam on a previous date? Yes No

If yes: Date:

Are you a licensed contractor: Yes No

State: Class: License #:

I have a minimum of 10,000 hours of experience in the Fire Sprinkler Industry Yes No

List your present or most recent employer first: Work Experience in Specialty: Hours:

Employer, City & Phone #	From Month/Year	From Month/Year

I do solemnly swear or affirm that the above statements are true. I further realize that falsification of these statements shall be cause for disqualification. By affixing my signature to this application, I agree to abide by the following rules and regulations of certification holders as set forth by the NITC certification committee. As a holder of an NITC certification I agree to not make any false claims about the scope of my certification(s); I agree to not utilize an NITC certification in any manner that portrays NITC unfavorably; and furthermore, I agree to not engage in false or misleading advertising of my NITC certification. I understand that NITC reserves the right to suspend or revoke my certification should I violate these obligations. Should my certification be revoked, I agree to cease and desist any and all references to being the “holder” of an NITC certification and shall return any certificates, including wallet sized photo identification cards, to NITC.

I agree to not utilize any written documents, reports, procedures, etc., with the NITC certification mark in any manner whatsoever that may be inaccurate or false.

I understand and agree that my examination results may be shared with the course instructor, training coordinator or training entity.

Signature

Date

If you would like to include any additional documentation, you can upload a pdf file along with this application below by choosing to upload a file.

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