Cathodic Protection Certification Application CP 1 - Cathodic Protection Tester

(Must be submitted to NACE Headquarters for certification to be complete) NACE Member: Applicant's Name: Home Address: Yes No Member #

Company Name: Company Address:

Country: Phone: E-mail: SIGNATURE: PRINTED NAME: Home Business

Zip/Postal Code: Fax

DATE:

REQUIREMENTS NECESSARY TO ACHIEVE CERTIFICATION: To achieve this certification, qualified individuals have two options: CLASSROOM TRAINING - CP1 - Cathodic Protection Tester course or EXAM ONLY OPTION - CP 1-Cathodic Protection Tester Exam Only APPLICATION PROCEDURE It is strongly recommended that Exam Only candidates submit a completed application for certification at least 60 days in advance so that work experience requirements and education prerequisites can be verified. RECERTIFICATION REQUIREMENTS Every three (3) years. Recertification requires a minimum of 2 years work experience in cathodic protection and 8 hours per year (24 hrs total) of professional development hours. SUBMIT COMPLETED APPLICATION AND SIGNATURE PAGES TO: MAIL TO: NACE INTERNATIONAL CERTIFICATION DEPARTMENT 1440 SOUTH CREEK DRIVE HOUSTON, TX 77084 FAX TO: 281-228-6311

If you have any questions, please contact Marie Newton in our Certification department at 281-228-6211 or by e-mail at marie.newton@nace.org.

AFFIRMATION I affirm that: 1. 2. I understand that I am solely responsible for making sure that all necessary work experience documentation is complete and submitted in good order to NACE Headquarters. I understand that if I knowingly provide, or cause to be provided, any false information in connection with my recognition under the NACE International Training and Certification Program, that it will be grounds for action against my understanding in the program.

3. I understand that the names of the categories within the NACE International Cathodic Protection Training and Certification Program are as follows: Highest Level Successfully Completed CP 1 CP 2 CP 3 CP 4 Category Title CP1-Cathodic Protection Tester CP2-Cathodic Protection Technician CP3-Cathodic Protection Technologist CP4-Cathodic Protection Specialist

4. NACE has a firm policy regarding the use of its logos and certification numbers and titles. The certification number and category title may be used only by NACE CP 1-Cathodic Protection Testers, NACE CP 2Cathodic Protection Technicians, NACE CP 3-Cathodic Protection Technologists, and NACE CP 4-Cathodic Protection Specialists, and may not be used by any other persons. All active CP card holders are permitted to use the term NACE CP 1-Cathodic Protection Tester, NACE CP 2-Cathodic Protection Technician, NACE CP 3-Cathodic Protection Technologist, or NACE CP 4Cathodic Protection Specialist (whichever level of certification attained) and their certification number on business cards. This example illustrates how this information can be used by a NACE CP 1-Cathodic Protection Tester. John Smith NACE CP 1-Cathodic Protection Tester, Cert. No. 9650 ACE Inspections, Inc., Knoxville, TN NACE CP 1-Cathodic Protection Testers, NACE CP 2-Cathodic Protection Technicians, NACE CP 3Cathodic Protection Technologists, and NACE CP 4-Cathodic Protection Specialists who are members in good standing of NACE International may display the NACE Logo for the purpose of identifying the individual as having achieved a NACE Certification. I understand that violation of these rules will result in action against my standing in the program on the basis of violation of the NACE International Cathodic Protection Program Attestation. 5. I (re)affirm the NACE International Cathodic Protection Certification Program attestation and agree to abide by its provisions as long as I hold any level of recognition under the program. Signed: Date:

THIS DOCUMENT MUST BE SIGNED AND RETURNED WITH APPLICATION RETAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS

ATTESTATION

I hereby:
(1) (2) (3) Recognize and acknowledge that the proper control of cathodic protection can be critical to the safety and welfare of the general public and industrial facilities. Recognize and acknowledge that the control of cathodic protection is obligatory to maximize conservation of our material resources, to reduce economic losses, and to protect the environment. Recognize and acknowledge that the entire field of cathodic protection and its control encompasses the application of the knowledge and experience of many diverse disciplines and levels of technical competence which must often be consulted. Recognize and acknowledge that only through continual association and cooperation with others in this field can the safest and most economical solutions be found to the many cathodic protection problems. Recognize and acknowledge that the quality of my work reflects on the entire profession of corrosion control.

(4)

(5)

For these reasons I: (1) Agree to give first consideration in my cathodic protection work to public safety and welfare and to protection of the environment. (2) Agree to apply myself with diligence and responsibility to the cathodic protection work that lies within my area of competence. (3) Agree to pursue my work with fairness, honesty, integrity and courtesy, ever mindful of the best interests of the public, my employer, and of fellow workers. (4) Agree to not represent myself to be proficient or make recommendations in phases of cathodic protection work in which I am not qualified by knowledge and experience. (5) Agree to avoid and discourage untrue, sensational, exaggerated, and/or unwarranted statements regarding my work in oral presentations, written text, and/or advertising media. (6) Agree to treat as confidential my knowledge of the business affairs and/or technical process of clients, employers, or customers when their interests so require. (7) Agree to inform clients or employers of any business affiliations, interests, and/or connections which might influence my judgment. (8) Agree to uphold, foster and contribute to the achievement of the objectives of NACE International. I understand that my failure to comply with these requirements could result in disciplinary action. Signature: Printed Name: Date:

THIS DOCUMENT MUST BE SIGNED AND RETURNED WITH APPLICATION RETAIN A COPY OF THIS DOCUMENT FOR YOUR RECORDS

S A M P L E Form 1: Summary of Cathodic Protection Related Work Experience Instructions: Make and use as many copies of this form as needed. Please provide all information requested. Forms must be printed legibly in black ink or typed. Illegible information can delay the application process. For assistance with this form, contact the Education Division at NACE International Headquarters. Applicant Information: Name: A. Sample Phone: 409/111-4321 Company: Address: City: ZZZ Coating Inspection Inc. 987 Gage Avenue Millspec State/Province: TX Country: USA Fax: 409/111-1234

Zip/Postal Code: 77987

Please summarize below the information on each copy of Form 2, Individual Job Documentation. List your experience beginning with the most recent, followed by less recent experience.

From Month/Year 1/92 12/89 12/87 / / / / / / /

To Month/Year 1/95 12/91 12/89 / / / / / / /

Number of Months in this job 36 24 24

Job Title CP pipeline readings Installer Design Manager

Company Name ZZZ Gas Co. AAA Tank Installers ABC CP Design

Applicant Affidavit: I understand that if I knowingly provide false information in connection with my recognition under this program, it will be grounds for disciplinary procedures. Signed: XXX Date:

Form 1: Summary of Cathodic Protection Related Work Experience Instructions: Make and use as many copies of this form as needed. Please provide all information requested. Forms must be printed legibly in black ink or typed. Illegible information can delay the application process. For assistance with this form, contact the Education Division at NACE International Headquarters. Applicant Information: Name: Phone: Company: Address: City: Zip/Postal Code: State/Province: Country: Fax:

Please summarize below the information on each copy of Form 2, Individual Job Documentation. List your experience beginning with the most recent, followed by less recent experience.

From Month/Year / / / / / / / / / /

To Month/Year / / / / / / / / / /

Number of months in this job

Job Title

Company Name

Applicant Affidavit: I understand that if I knowingly provide false information in connection with my recognition under this program, it will be grounds for disciplinary procedures. Signed: Date:

WORK EXPERIENCE FORM 2: INDIVIDUAL JOB EXPERIENCE

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Use one of these forms for each period of work experience (job) you wish to document. Make and use as many copies of this form as you need. Please provide the information requested per the directions and definitions provided. ____________________________________________________________________________________ Job Information Applicants Name: ________________________ Job Title: _______________________________ Company: ______________________________ From: Month ______________ To: Month ______________ Year _______ Year _______ Who can NACE contact to verify this experience Name: _________________________________ Company: ______________________________ Address: _______________________________ State/Province: __________________________ Zip/Postal Code: _________________________ Phone: _________________________________ Fax: ___________________________________ E-mail: _________________________________

C.2 WORK EXPERIENCE FORM 2: INDIVIDUAL JOB EXPERIENCE

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Describe in detail what are/were your cathodic protection related duties in this job. (Do not write on the back of this form). You may attach additional single sided sheets) THIS SECTION MUST BE COMPLETED Your application will be returned if this space is left blank _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Signed:

Date: _________________________

MAKE A COPY OF ALL PAGES OF THIS APPLICATION FOR YOUR RECORDS