FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION



-384175-519430005674360-52932600NTC INSTRUCTOR CERTIFICATION PROGRAM APPLICATION Please complete and submit this form and all supporting documents to: NTC-Certification@. For additional information on the NTC Instructor Certification Program, please refer to the program manual.APPLICANTSTATE POC / FEDERAL SUPERVISORName: FORMTEXT ?????Name: FORMTEXT ?????Email Address: FORMTEXT ?????Email Address: FORMTEXT ?????Telephone: FORMTEXT ?????Telephone: FORMTEXT ?????Mailing Address: FORMTEXT ?????Mailing Address: FORMTEXT ?????LEVEL OF CERTIFICATION FORMCHECKBOX Presenter FORMCHECKBOX Instructor FORMCHECKBOX Master Instructor COURSE CONTENT DOMAIN FORMCHECKBOX Cargo Tank Inspection FORMCHECKBOX Cargo Tank Facility Review FORMCHECKBOX Enforcement Procedures FORMCHECKBOX General Hazardous Materials FORMCHECKBOX Household Goods FORMCHECKBOX Investigative Safety Analysis FORMCHECKBOX Skill Performance Evaluation FORMCHECKBOX New Entrant Safety Audit FORMCHECKBOX North American Standard Part A FORMCHECKBOX North American Standard Part B FORMCHECKBOX Other Bulk Packaging FORMCHECKBOX Passenger Vehicle Inspection FORMCHECKBOX Roadside Enforcement FORMCHECKBOX Other: FORMTEXT ?????MINIMUM QUALIFICATION CHECKLISTPRESENTER: FORMCHECKBOX Professional experience relevant to the course content or topic area(s) in which certification is sought (e.g., CVSA/FMCSA certification; completion of relevant inspections/investigations, etc.). Please attach resume.INSTRUCTOR: FORMCHECKBOX Successful completion of the NTC course(s) in which certification is sought. Please attach certificate FORMCHECKBOX Two (2) years of professional experience relevant to the course content or topic area(s) in which certification is sought (e.g., CVSA/FMCSA certification; completion of relevant inspections/investigations, etc.). Please attach resume.MASTER INSTRUCTOR: FORMCHECKBOX Currently a certified NTC Instructor. FORMCHECKBOX Delivered a MINIMUM of fifteen (15) Tier 2 NTC course administrations. FORMCHECKBOX A documentable negative feedback (DNF) rate NO HIGHER THAN 20.0% over Instructor tenure.APPLICATION CONFIRMATIONI, FORMTEXT Supervisor's Name, hereby recommend the applicant identified above to serve in the requested capacity for NTC. Furthermore, I certify that the applicant is a subject matter expert and meets all minimum qualifications to serve in this capacity. I also authorize the applicant to fulfill his/her certification maintenance requirements. FORMTEXT ????? FORMTEXT ?????Supervisor’s Printed NameSignatureDate (MM/DD/YYYY)I, FORMTEXT Applicant's Name, meet all the minimum qualifications to serve in the requested capacity and agree to fulfill the certification maintenance requirements necessary in order to maintain my certification. FORMTEXT ????? FORMTEXT ?????Applicant’s Printed NameSignatureDate (MM/DD/YYYY) ................
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