Notary public - Ohio Department of Commerce

Application for Examination (please type or print)

Examination

% Certificate #

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:______________________________________ Address:____________________________________ City:___________________ St:________ Zip:______

Employer Name:______________________________ Address:____________________________________ 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 (1pt. maximum) Name o f Course

B) Technical Curriculum (2pt. maximum) Type of certificate

C) College/University(non engineering /associate's degree (3pt maximum) Name o f University D) College/University (engineering degree 4 pt maximum) Name o f University

Dates taken

Results

from

to

Date received

Course of Study Degree

Type of degree

Office use only Pt. earned

Office use only Pt.

Office use only Pt earned

Office use only Pt.

Bureau of Operations & Maintenance - Boilers 6606 Tussing Road Reynoldsburg, OH 43068-9009 Form Number: DIC 4316 Date Updated: 3/2019

An Equal Opportunity Employer and Service Provider

614-644-2223 Fax 614-728-1397 TTY/TDD 800-750-0750

com.

Experience (1 pt Minimum 4 pt Maximum) Credit 1 point for each year's technical experience with boilers or

pressure vessels

A) Engineering, design or design registration (Canada) Period of employment

Office use only

Employer

From

to

Pt earned

Name

From

to

B) Manufacturing, includes fabrication methods or process Period of employment

(shop/field)

From

to

Employer

From

to

Name

Office use only Pt earned

C) Responsible charge in the operation of 50,000 lbs steamPeriod of employment

hour cap.

From

to

Employer

From

to

Name

Office use only Pt earned

D) Perform repair, alternation or maintenance of boilers/pr Period of employment

vessels

From

to

Employer

From

to

Name

Office use only Pt earned

E) Quality control system related to boiler/pressure vessel Period of employment

mfr./repair

From

to

Employer

From

to

Name

Office use only Pt earned

F) Inspection of boiler/pressure vessel /in service or during Period of employment

construction

From

to

Employer

From

to

Name

Office use only Pt earned

G) As an NDE Level II examiner of boiler/pressure vessel Period of employment

Employer

From

to

Name

From

to

Office use only Pt earned

Previous examinations taken _____________________________________________________________________

By the below signature, applicant attest that the education and experience stated in this application is correct and, further agrees to abide by the National Board Rules for Commissioned Inspectors and all other standards applicable.

Signature of Applicant

Date_________________

This application must be sworn to before a Notary Public

Sworn to and subscribed before me this

day of

,

Notary public

Bureau of Operations & Maintenance - Boilers 6606 Tussing Road Reynoldsburg, OH 43068-9009 Form Number: DIC 4316 Date Updated: 3/2019

An Equal Opportunity Employer and Service Provider

614-644-2223 Fax 614-728-1397 TTY/TDD 800-750-0750

com.

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