Form Dic4316 - Application For Examination Examination Certificate

ADVERTISEMENT

Ohio Department of Commerce
John R. Kasich
Governor
Division of Industrial Compliance
Bureau of Operations and Maintenance
Andre T. Porter
6606 Tussing Road
P.O. Box 4009
Director
Reynoldsburg, OH 43068-9009
(614) 644-2236 FAX (614) 644-2428
Application for Examination (
Examination _______% Certificate #____________
please type or print)
IMPORTANT--------READ CAREFULLY
1) This application must be on file in the office of the Division of Industrial Compliance, Reynoldsburg,
Ohio , on or before the tenth day of the month preceding the date of the examination.
2) Examinations are held at the National Board Training Center in Columbus, Ohio on the first Wednesday in
March, June, September and December of each year.
3) The examination fee of $150.00 (one hundred fifty dollars) payable to Treasurer State of Ohio, must
accompany this application.
4) A letter from one or more previous employer must accompany this application verifying experience and
character.
5) Failure to comply with any of the above requirements will debar applicant from taking the examination.
6) Consult the National Board of Boiler and Pressure Vessel Inspectors Publication “By-Laws for further
requirements.
I hereby make application for a Certificate of Competency as an Inspector of Boiler and Pressure Vessels for the
State of Ohio, and certify that the following statements are true. Applicant shall have a minimum of 5 credit points
accumulated under education & experience
Name__________________________________________
Employer Name_______________________________
Address________________________________________
Address ______________________________________
City__________________St____________Zip_________
City__________________St__________Zip_________
Mandatory Requirement (Must have as a minimum) List name of high school or course where a diploma or GED
Equivalent was received
School/Course__________________________Dates of attendance________to________Date Received
Education (1 pt Minimum, 4 pt. Maximum)
A) Technical training in Boiler & Pressure Vessel Inspection
Dates taken
Results
Office use only
(1pt. maximum)
____from ____to
Pt. earned
Name of Course
B) Technical Curriculum (2pt. maximum)
Date received
Office use only
Type of certificate
Pt. earned
C) College/University(non engineering /associate’s degree
Course of Study
Degree
Office use only
(3pt maximum)
Pt earned
Name of University
D) College/University (engineering degree 4 pt maximum)
Type of degree
Office use only
Name of University
Pt. earned
FINANCIAL INSTITUTIONS • INDUSTRIAL COMPLIANCE • LIQUOR CONTROL • REAL ESTATE AND PROFESSIONAL LICENSING • SECURITIES • STATE FIRE MARSHAL • UNCLAIMED FUNDS
“An Equal Opportunity Employer and Service Provider”

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2