Application Form

API 510, Pressure Vessel Inspector Certification Program

[9/

New Certification

Personal Data

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Social Security Number

Name (First, Middle, Last)

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[Link]\C>~ Home Address (Number and Street)

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Number

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City, State and Zip Code

Date of Birth

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Employer Data
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Fax Number

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Employer's

Address (P.O. Box or Number and Street)

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Business Ema;!.

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City, State and Zip Code

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uAECountry Please indicate at which address you wish to receive API-related materials: Are you interested in being included in the API Inspector Directory, when you obtain your certification? Please indicate which address you wish to have included in ICP Directory listing.

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Cell Phone or Pager Number

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Home

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Home

No

.b:Y" Work

09/05 For Accounting Use Only: SS-2 100-D9200-7 I 10

32

Education and Training

API 510, Pressure Vessel Inspector Certification Program

High School

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Name Location

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Location

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Year Graduated

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Name

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Year Graduated

Trade School
Name Location Field of Study Year Graduated

Name

Location

Field of Study

Year Graduated

Name

Location

Field of Study

Year Graduated

Name

Location

Field of Study

Year Graduated

College

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Dates Attended Major

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Degree Type

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Name

Year Graduated

Name

Dates Attended

Major

Degree Type

Year Graduated

Name

Dates Attended

Major

Degree Type

Year Graduated

Name

Dates Attended

Major

Degree Type

Year Graduated

09/05 For Accounting

33
Use Only: SS-2 100-D9200-7 I 10

Inspection Employment History

API 510, Pressure Vessel Inspector Certification Program
(Last three employers or at least the last three years)

1.

Name and Address of Employer (Current) Employer

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Date of Employment 1.,11-./ ---!..,... /'40 [Link] 261'S

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Mailing Address (Number and Street)

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City, State and Zip Code

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Employer's Telephone Job Title/Brief Description

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Name and Address of Employer

Date of Employment From: .:>

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Employer

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Employer

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34

09/05 For Accounting

Use Only: SS-2 100-D9200-7

Qualification Method
API 510, Pressure Vessel Inspector Certification Program

Please place a check by the method under which you are qualified to be certified as a pressure vessel inspector.

W A. o

Written Examination Under API Standard 510 (Complete Test Registration Form next page)

B. Successfully passed exam for the National Board of Boiler and Pressure Vessel Inspectors Owner-User Commission or Certificate of Competency.
In which jurisdiction Please provide: ? ? ? ? Proofthat candidate has successfully passed the exam for NB commission, of Competency; AND OR did you take the test? Date:

A copy ofyoUf Commission A completed

or Certificate

PVICP Application

Form; AND Form to verify work experience. (A form for each employer

A notarized Employment is required.); and The applicable certification

Reference

fee in U.S. dollars, payable to the American

Petroleum

Institute.

ATTENTION: NATIONAL BOARD CERTIFICATION ONLY FOR THE FIRST-TIME QUALIFICATION METHOD IS VALID

510 APPLICANTS

09/05 For Accounting Use Only: SS-2100-D9200-7110

35

Your Name: API 510 Test Registration

Examination Locations and Dates

VI brlUt

This form may also be used to reschedule a test or register for a retest. Please indicate method of payment using page 43.

Please indicate which API 510 Inspector Certification Examination you wish to take: [9/"June 7, 2006 (Application Deadline March 31, 2006)

December 6, 2006 (Application Deadline September 26, 2006) no exceptions are made.

Please note that the application deadlines are firm -

Please indicate your preferred testing location. Every effort will be made to assign you to the location of your choice. Seatin!! is limited: aDDlyearly to !!et the location of your choice. Site may be changed

after the deadline; see details in front of application package.

* A sitting fee will be required at these locations.

o o o o

California: Oakland* California: Los Angeles Louisiana: Baton Rouge Maryland: Baltimore*

o o o o

Minnesota: St. Paul * Oklahoma: Oklahoma City* Pennsylvania: Harrisburg* Texas: Corpus Christi

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" V'--

Texas: Houston Utah: Salt Lake City* West Virginia: Charleston*

Q) 7. v--cL. 2:--OR.

"'-'I V ~d) " -i

1\\3\.) DHABI

Canada

(j)UAE.

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Alberta: Edmonton*

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0

British Columbia: Vancouver*

Elsewhere: Bahrain

(please contact API to verify availability of these sites) Singapore

Trinidad

ATTN: API can organize a test site anywhere in the world if there is sufficient interest. Please contact us for details, if your preferred location is not on the list. If you are scheduling a retest, please remember to provide along with this form: A notarized Employment Reference Form(s) to validate recent work experience; and The certification fee in U.S. dollars, payable to the American Petroleum Institute.

09/05 For Accounting Use Only: SS-2100-D9200-711O

36

Inspector Certification Agreement

(Effective on Date of Inspector's Certification)
This Agreement is between the American Petroleum Institute (hereinafter "API"), a corporation of the District of Columbia, having an office at 1220 L Street, N.W., Washington, D.C. 20005, and the Applicant (the "Inspector"), residing at the address noted below. Whereas, API's Individual Certification Programs ("ICP") certify inspectors and other technical personnel that meet the guidelines and requirements specified in the program. Whereas, Inspector desires to obtain certification under the API ICP program. Now therefore, in consideration of the mutual covenants hereinafter stated, the parties agree as follows: 1. Inspector agrees to comply with all of the program policies and requirements. Inspector agrees and understands that API shall be the sole judge or whether the Inspector has the appropriate qualifications to become certified, remain certified, or to be recertified. 2. The Inspector agrees not to make any misrepresentations concerning the Inspector's certification status or the program. The Inspector agrees not to perform any acts, which directly or indirectly assist a third-party in making any misrepresentation relating to the ICP program. The Inspector understands and agrees that the ICP Program is designed to assist users in identifying inspectors who have satisfied the minimum qualifications specified in the applicable industry standards and that API does not warrant or guarantee the competency of any inspector certified under this program. The inspector agrees not to mislead customers or the public about the scope and purpose of this program. The Inspector authorizes API to release information to regulatory agencies, current or potential employers, or other interested parties concerning the inspector's certification status. API agrees to take reasonable measures to ensure that any information that is released is accurate. However, API does not warrant or guarantee the accuracy of any information that is released and specifically disclaimers any liability relating to the release of this data. The Inspector understands and agrees that the Inspector's certification will not be renewed unless the inspector satisfies all of the program requirements for renewal and submits the appropriate recertification application and renewal fee to API within the time frame specified by API. Inspector understands and agrees that API may modify the requirements for an inspector to obtain, maintain, or renew the certification at any time. If API's requirements are modified, API shall determine the date by which the new requirements become effective. Inspector agrees to comply with the modified requirements within the deadline specified by API. API agrees to attempt (but assumes no duty) to notify Inspector of significant changes to the program by either giving notice: (1) at the Inspector's last known address, or (2) the Inspector's last known e-mail address, or (3) by posting the changes on the API website. It is the responsibility of the Inspector to notify API of address changes. The failure of API to notify Inspector of a renewal date or modification of the program does not relieve the Inspector of the responsibility to file a timely renewal application or to comply with new certification requirements. It is the responsibility of the Inspector to obtain this information by contacting API or by checking the API website for updates. If any action or proceeding is brought by API to enforce, protect or establish any right or remedy with respect to this Agreement or with respect to the subject matter of this Agreement, API shall be entitled to recover reasonable attorney's fees and costs provided that it is the prevailing party. Inspector agrees to indemnify API for any losses or damages resulting from the breach of the terms of this Agreement by the Inspector. The Inspector agrees and understands that API may terminate an inspector's certification if API determines that the inspector has: (1) made material errors, omissions, or misrepresentations on the application or in documents submitted to API, or (2) violated any terms or conditions of this Agreement or any ICP policies or requirements. API also may terminate the program at any time and for any reason deemed appropriate by API. Upon termination, with or without cause, of any rights or authority conferred by this Agreement, or upon expiration/termination of the Inspector's certification, Inspector agrees to return all certification documents to API within 30 days.

3.

4.

5.

6.

7.

8.

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37

9.

The Inspector shall not use any trademark of API or name of API including any abbreviation thereof, in any publicity, advertising, or for other promotional purposes without the prior written approval of API.

10. The Inspector agrees to comply strictly with all U.S. export laws relating to this program. The Inspector warrants that he is not located in, or under the control of, or a national or resident of any embargoed countries. 11. This agreement shall not and is not intended to benefit or to grant any right or remedy to any person or entity that is not a party to this Agreement. 12. This instrument contains the entire and only agreement between the parties. representations not herein contained shall have any force and effect. 13. Paragraphs 2, 3, 4, 5, 6, 7, and 8 survive termination of this agreement. 14. It is expressly understood between the parties hereto that no association, agency, apparent agency, employer/employee relationship, partnership, or joint venture of any kind has been created. Inspector agrees not to refer to himself as API's agent nor refer to the relationship between the parties as a joint venture or partnership or any in manner inconsistent with this Agreement. Inspector shall have no authority to act or contract on behalf of API. 15. No waiver API of any default, misrepresentation, or breach of warranty or covenant hereunder, regardless of whether intentional, shall be deemed to extend to any prior or subsequent default, misrepresentation, or breach of warranty or covenant hereunder or affect in any way any rights arising by virtue of any prior or subsequent such occurrence. 16. API makes no express or implied warranties regarding the ICP program or potential benefits of the certification to the Inspector. 17. The Inspector agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by any government body or authority based on in any way measured by this Agreement, or any portion or it, or any services related thereto. 18. Inspector understands and agrees that Inspector is not granted any rights under the program or this Agreement until API has determined that the Inspector has satisfied all of the program requirements and has issued a Certificate to the Inspector. The Inspector's certification shall be effective on the date that is noted on the Certificate and shall be effective for a period of three years unless terminated pursuant to the terms of this Agreement. 19. This Agreement shall be governed by and construed in accordance with the laws of the District of Columbia, USA, without regard to the rules regarding conflicts of law. The parties agree that any action, suit, or proceeding based upon any matter, claim, or controversy arising hereunder or relating hereto shall be brought exclusively in the federal or state courts located in District of Columbia, USA. The parties consent to the jurisdiction and venue of such courts, and waive any objections to the jurisdiction and venue thereof. I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agree to comply with the conditions specified above. No oral statements or

Applicant's name (please print) ~~fr-~'T~{2- _

A~I-Tc"''f

'{I ~liZF\

----~----------Signature of Applicant Applicant's address:

J_'b1~~19-~-----Date

API Reviewer's

Initials:

09/05 For Accounting

38
Use Only: 88-21OO-D9200-7110

Inspector Application Agreement (for Initial and Renewal Certification)

(Effective Upon Receipt of Application)
The applicant agrees to the following conditions: 1. API agrees to evaluate the applicant's qualifications to determine if the Inspector satisfies the requirements of the ICP program. Applicant understands and agrees that: (1) API will not issue an ICP certificate to the Applicant unless API determines that an Applicant meets all of the requirements and Applicant has submitted the applicable fees and documentation within the specified time frame, and (2) API shall be the sole judge of whether the Applicant has the appropriate qualifications to become certified, remain certified, or be recertified. 2. The Applicant agrees to pay the applicable fees, comply with all of the program requirements and submit any supplemental information or documents deemed necessary by API to verifY an applicant's qualifications. Applicant understands and agrees that API does not represent or warrant that the submission of the fees and materials by the Applicant will result in the Applicant being certified under the program. 3. Each new application remains valid for a period of 18 months from the date of receipt by API. API administers ICP exams every 6 months. Therefore, API grants each applicant three consecutive attempts during the l8-month period to sit and pass the test, starting with the first exam administration the applicant registers for. Applicants must pass the exam within these three consecutive exam administrations. If an applicant fails to appear for the test, cancels his/her appearance and reschedules, or takes the exam and fails it, it will count as an official attempt. 4. If the applicant does not obtain a certification within this period of time and still wishes to obtain the certification, they must start the application process again, including re-submission of a full fee and a complete new application. 5. All requests for refunds must be submitted in writing by mail or by fax to API no later than 1 year from the date payment was received by API. Requests for refunds received after this one-year period cannot be fulfilled. 6. An applicant is entitled to a full refund of the application fees only if API receives the refund request prior to the exam application deadline (usually 11 weeks before the exam date). 7. An applicant is entitled to a 50% refund of the application fee ifthe refund request is received by API within 1 year from the date payment was received by API. 8. No refunds will be made if an applicant has taken the test and failed. 9. For normal processing API must receive recertification applications prior to the current certification's expiration date. Recertification applications must be mailed, as API requires the original of the notarized page. 10. API may extend the certification term for 3 (three) months after the expiration date. Inspectors will remain authorized during that period of time. Recertification applications received by API within this extension term will be processed, but a $150 late fee will be required. 11. Inspectors who do not apply for recertification within three months after the current certification expiration date will be decertified. 12. Circumstances such as heavy work schedule or work in other countries do not relieve the applicant of the responsibility to file a timely renewal application. 13. Applicant understands and agrees that API may modifYthe requirements for an applicant to obtain, maintain, or renew the certification at any time. If API's requirements are modified, API shall determine the date by which the new requirements become effective. Applicant agrees to comply with the modified requirements
09/05 For Accounting

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Use Only: SS-2 100-D9200-7 I 10

within the deadline specified by API. API agrees to attempt (but assumes no duty) to notifY Applicant of significant changes to the program by either giving notice: (1) at the Applicant's last known address, or (2) the Applicant's last known e-mail address, or (3) by posting the changes on the API website. It is the responsibility of the Applicant to notifY API of address changes. The failure of API to notifY Applicant of a renewal date or modification of the program does not relieve the Applicant of the responsibility to file a timely renewal application or to comply with new certification requirements. It is the responsibility of the Applicant to obtain this information by contacting API or by checking the API website. 14. The Applicant agrees to comply strictly with all U.S. export laws relating to this program. The Applicant warrants that he is not located in, or under the control of, or a national or resident of any embargoed countries. 15. The Applicant agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by any government body or authority based on in any way measured by this Agreement, or any portion or it, or any services related thereto. 16. Applicant warrants and represents to all information that is being submitted pursuant to this is complete and accurate. Application understands that API is relying upon the accuracy of this information in evaluating the Inspector's qualifications. Applicant agrees to indemnifY API for any claims, losses, or damages resulting from the Applicant submitting inaccurate or misleading information. I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agree to abide by the policies and regulations specified above.

~Signature of Applicant Date API Reviewer's Initials _

09/05 For Accounting Use Only: SS-2 100-D9200-7 I 10

40

Employment Reference Form

API 510, Pressure Vessel Inspector Certification Program
Note: This form applies to API 510 and must cover an aggregate of the required amount of experience based on education. This experience must be current to within 3 years of expected certification (5 years for those without high school education). This form may need to be updated ifthe experience is no longer current relative to certification date. Applicant's Name: Social Security Number: Company:

\J A-L'T PtL

AN

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(~V
I

V {(."{~ff

yf
Address

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("<.

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Title.)

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Name of Supervisor

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-6

'Ou.h
Affirms that

8' 4 :Z.. "I

Telephone Number Worked for

WCll t-..;_
Name of Applicant

(~' l;'.~1 I{}'<

.),-1 V,.{t\[Link]
Company

eft! L.4.,

from

6/ j?-/ c?
Be~nning' Date

Lj

to

6)
f

C&/

S-

'Ending Date

Supervisors please fill in the blanks below. Your notarized signature on this page validates the following: During the period indicated above the applicant has acquired the following experience (please circle the applicable activities): Activity
Design Repair

How much time was spent in inspection?

Construction V Operation Inspection of pressure vessels

L---""

~M V,-\v...."'2-;5, Yrs --- Mos --Total length of experience acquired:

Yrs Mas

---

--

ALL APPLICANTS MUST HAVE THE AREA BELOW COMPLETED AND NOTARIZED
SUPERVISOR'S NAME (PLEASE PRINT)

pIi,

t;~

0 cj ,It. c,.-

__vC' ~
Supervisor's Signature Subscribed and sworn to before me the Date day of

~~jC2!L~
.. ,

_
.

Notary's Signature My commission expires

Notary Public

Date _

09/05 For Accounting Use Only: SS-21 00-D9200-7110

41

Employment Reference Form

API 510, Pressure Vessel Inspector Certification Program
Note: This form applies to API 510 and must cover an aggregate of the required amount of experience based on education. This experience must be current to within 3 years of expected certification (5 years for those without high school education). This form may need to be updated ifthe experience is no longer current relative to certification date. Applicant's Name: Social Security Number: Company: \,,(

A-Ll ~

AN '\

(fz.N , V

V (Ft

~ff

Name of Sup rvisor <..dl ~ , Address Affirms that

:' i ':A G'=1t~L

J>

Title ('50 G6')_C-j.J-:SI Telephone Number

0)oj
.~,I(/~

((?y

Worked for

DoC'l~,C\ \
Company

Name of Applicant from :- c. / ( Ie .:....-;, .. BegInnIng Date

(

to

21/Di/d7-f
Endmg Date
I "

Supervisors please fill in the blanks below. Your notarized signature on this page validates the following: During the period indicated above the applicant has acquired the following experience (please circle the applicable activities): Activity
Design Repair
L./"

How much time was spent in inspection?

C "'<2
Yrs

__:::~_ r
Yrs

Construction Operation

~ ~

Total length of experience acquired:

Inspection of pressure vessels

---

---

Mas

ALL APPLICANTS MUST HAVE THE AREA BELOW COMPLETED AND NOTARIZED
SUPERVISOR'S NAME (PLEASE PRINT)

tvl(. o eS l... cI
V'

Id

(\ \/u-" I,.

C\.

v-

_~
Supervisor's Signature Subscribed and sworn to before me the Date day of

~5_~_Oj~~~~----~, "

Notary's Signature My commission expires

Notary Public

Date _

09/05 For Accounting Use Only: SS-2100-D92 00-71 10

41

Supplemental Information
API 510, Pressure Vessel Inspector Certification Program
1. Do you currently have an active API certification? If yes, enter your certification number and expiration date. If you answer yes, you need not complete the Education and Training Form.

Yes

~o

570 Certification Number 653 Certification Number QUTE Certification Number

Expiration Date Expiration Date Expiration Date

2.

Are you currently a full-time, non-contract employee of an API member company? If yes, please enter the company name.

DYes

G:V'No

3.

Please check the boxes that correctly describe your organization. Please be sure to check one box on each side. Industry Organization type

PETROLEUM CHEMICAL PAPER/PULP ALL OTHER

0
~ ~

OWNER- USER INDNIDUAL CONTRACTOR INSPECTION COMPANY CONSULTING/CONSTRUCTION OTHER

W
0 0 0
4.

cg-0

Please check the boxes that correctly describe your employment status. Please be sure to check one box only.

o
cg.----

Full-time employee of an owner/user Full-time employee of an inspection agency/other company Independent contractor

o
I.

Discounts for the API Inspector Certification Program are being offered ifthe applicant meets one of the following criteria: Currently certified as an API Authorized InsJl:ctor in any other ICP program.

2. A full-time and permanent employee of a company currently paying membership dues to the American Petroleum Institute. If your company does not meet criteria #2, you must pay the nonmember price.

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42

API 510 Initial Certification Fees

API member rate applies to full-time, 2006 Rates: non-contract employees of API-member companies.

API Member
Number of other API Certifications you already have No other current API Certifcations Current 570 or 653 API certification Certification Fee

Non Member
Certification Fee
~.

600 550

800
750

\/

Payment Type
Charge Card : Card Number:

g-

Visa

o
M 0 HAM
E r)

American Express Expiration Date:

MasterCard

-4 g :5f .4 q 2 &-

2 b4 0 / 00 I

Name as it appears on card Signature

S.H A H b G:{L N ~I
Total Submitted
Certification fee

o Check o Purchase
Order

>%
P.O. Number Total:

~0o/~

Penalties/Other

Bank fee (if wired)

g c'c;/----

Wire Transfer to

Citibank, F.S.B. Washington, DC 20036-0967 ABA Routing No. 254070116 Credit to: American Petroleum Institute Account No. 6672 -0060 Reference: Applicant's name and SS-2100-D9200-711O For wire transfers please make sure to include pertinent bank fees.

09/05 For Accounting Use Only: SS-2100-D9200-7110

43

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