EXAM NO: REG NO: APPLICATION FORM FOR CERTIFICATION, RENEWAL & RE-CERTIFICATION FOR IN-SERVICE INSPECTORS OF PRESSURE EQUIPMENT New Certificate Desired * In Service Inspector (Pressure Equipment) A, B & E * Senior In Service Inspector (Pressure Equipment) C & D Re-Sit A B C D E F Renewal ISI SISI Re-Certification (Paper F) DID YOU ATTEND AN AICIP TRAINING COURSE Y N COURSE TAKEN AT: I, Title Given Name Middle Name Family Surname hereby apply for AICIP Assessment, Examination and Certification, Renewal or Re-certification as indicated above. DETAILS OF APPLICANT I wish to sit my examination on / / at (STATE/VENUE) Street Address: Suburb: State: Postcode: Drivers Licence No: Date of Birth: Home Phone: Email: Mobile: BUSINESS/EMPLOYER Name: Address: Street Address: Suburb: Postcode: Phone Number: Fax Number: Work Email: REQUIRED ATTACHMENTS: Applicant Resume (attach) for new Application only Photocopies of qualification & Training: for new Applications only A recent passport photo (your name on the back) Fee (Refer Dates/Fees) 5 Inspection Reports for Renewals & Recertification only Letter from your current employer detailing work undertaken for Renewals & Recertification only Declaration METHOD OF PAYMENT - TAX INVOICE (COMPANY) Amount: $ Direct Debit details ~ Account Name: AICIP BSB: 082-330 Account No: 680767108 National Australia Bank 28 George Street, Parramatta, NSW 2150. TAX INVOICE/RECEIPT (CANDIDATES NAME) Cheque Direct Debit (Attach Remittance) MasterCard VISA (for any Credit Card payments please complete the separate credit card authorisation) DECLARATION I, of the above address do hereby declare that the above and all other information attached is correct. I also acknowledge that I have read (Information for Applicants), and if certificated, renewed or re-certificated by AICIP, I agree to abide by the conditions therein. Signature of Applicant: Date: Details of Witness: (JP, Police Officer, Clergyman, Registered/Professional Engineer) Name: Signed: Position: Date: AICIP APPLICATION FORM Controlled Copy 1
APPLICANT S RESUME FOR NEW CERTIFICATION NAME... QUALIFICATIONS (please use abbreviations) Trade Qualification/Certificates Title Body and Location Date Associate Diploma, Advanced Certificate University Degree Other IN-SERVICE INSPECTOR TRAINING (Please exclude qualifications listed above. List training location, equivalent full-time hours and dates). Self-Education & (Correspondence) Education body (TAFE, ATTAR) etc. Course/Training Body and Location Hours Dates Employer (In house training) Other EXPERIENCE (Please indicate appropriate background experience in equivalent full time years) General Engineering- Office Main Duties Employer Years General Engineering - Office In-service Inspecting AICIP CANDIDATE RESUME Controlled Copy 2
INDUSTRY EXPERIENCE Months must cover the last 5 years. The inspection reports submitted should provide evidence of the PE equipment listed below. Pressure equipment type (must cover at least 3 different types of equipment) Product Codes & Standards Total number of months spent on PE over the last 5 years MINIMUM TOTAL REQUIRED = 24 MONTHS MAXIMUM 60 MONTHS Total REFEREES Provide contact details of your employer(s) OR 5 customers who can confirm work over the last 5 years; all details must be provided. PE Equipment Listed above EMPLOYER/S AND/OR CUSTOMERS DATE/YEAR COMPANY* CONTACT NAME* TELEPHONE NO* AICIP INDUSTRY EXPERIENCE AND REFEREES Controlled Copy 3
CONTINUING PROFESSIONAL DEVELOPMENT (CPD) (over the last 5 years) Note: Credited hours = total hours involved except for (e) where only half the actual hours can be accredited. TITLE/ BODY/PROVIDER TYPE DESCRIPTION (AND CONTRACT DETAILS) CREDIT TOTAL HOURS INVOLVED a) Qualifications or Awards gained (since application for initial ISI or SISI Certificate) NDT, Coating, Thickness Testing, Mechanical Engineering (max. = 50) b) Formal Education Training Courses (other than a) (Safety valves, risk based inspection, non-intrusive inspection, OH&S requirements, report writing, nonintrusive inspection techniques, NDT (max. = 50) c) Conferences, Seminars, Professional meetings d) Presentation of Papers, Lectures. Writing of papers e) Informal learning (private study) f) Informal learning (on- the -job training) (max = 20) g) Service activity to others eg. examiner, audit, reviews, committee meetings MINIMUM TOTAL CPD REQUIRED: 100 HRS AICIP CONTINUING PROFESSIONAL DEVELOPMENT Controlled Copy 4
CREDIT CARD PAYMENT AUTHORISATION FORM About this form This form can be used for providing payment by credit card for all AICIP services. Please attach this form to any relevant completed application form and/or associated documentation to ensure fast processing of your payment. Once payment has been accepted this form will be destroyed. Disclaimer AICIP does not accept any responsibility for events arising from unauthorised access to the information included on this form. Post: PO Box 7622, Melbourne VIC 3004 Email: admin@aicip.org.au Phone: (03) 9867 0197 PART 1: PAYMENT DETAILS Fields marked with * are the minimum required to process payment Please charge my credit card for payment of:* Candidate/Company Name:* Examination Details Examination No. (if applicable) Payment amount* $ Invoice No. PART 2: CARD HOLDER DETAILS Note: Any reimbursement due will go to the card holder Name on Card* Address * Suburb* Postcode* Mobile Business Phone Fax Home Phone Email PART 3: CARD DETAILS Note: Credit card payments may be subject to a merchant fee surcharge MasterCard Visa Card Number* Expiry Date * CVC* Signature* Date* Personal information collected from you is held and used by AICIP under the provisions of the Privacy and Personal Information Protection Act 1998. The supply of information is voluntary, however if you cannot provide, or do not wish to provide the information sought, AICIP may be unable to process your request. If you require further information, please contact AICIP directly on 03 9867 0197.