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Medical Gas Instructor Recertification Examination Request

(This request form is for the 2018 instructor written re-certification).

* The fee per examination is $49.00 dollars. This must be prepaid. Please
make check 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 (3) weeks prior to
examination date. Please e-mail

*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**)

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:

You can upload pdf application files along with this request by choosing to upload a file below.  Examination Request will be denied if completed application are not submitted.