510-Recert-App_01-2012_revised2

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510 recert (rev) 01/2012 1

Application Forms for Recertification Only

API 510, Pressure Vessels Inspector Certification Program

1. This application is a writable PDF. Please make sure to download the application document

and save it on your computer. You can then open the application, type in your information, andprint the application forms. (Any application filled in while viewing it online will not be saved,nor will it be sent to API electronically.) All applications must be mailed to API.

2. Fill out all pages of this application completely.

3. Please enter your name as it appears in your passport / government-issued ID / driver’slicense.

4. Please include your certification number where indicated in the form.

5. Be sure to include a unique and current e-mail address. All API correspondence will be sent to

the e-mail address you provide.

6. You must include a verified Employment Reference Form (ERF). The ERF may be validatedeither by a public notary or by your employer. See Page 5 for full instructions.

7. Read and sign BOTH Inspector Agreements.

8. Include the re-certification fee. We will not process any application until ful l payment isreceived.

9. Be sure to keep a copy of the completed application that you mail to API, including copies ofyour ERF and employer letter, etc.

10. When you have completed your application see checklist at the back of this packet to ensureyou have included all the information and documents necessary.

ATTENTION: An inspector needs to take the quiz for recertification every 6 years, or every otherrecertification. Please be sure to take the recertification quiz, if you are due for one. If you have nevertaken a quiz, and have been certified for 6 years or longer you are due to take it.

To take the quiz please log into www.api.org/MyICP



510 recert (rev) 01/2012 2

Application Form for Recertification Only___________API 510, Pressure Vessel Inspector Certification Program

510 Certification #_________________________ Expiration Date__________________________

___________________________________________________________________________________________FIRST MIDDLE LAST

NAME (please spell it the same way as it appears on your passport / driver’s license)

Home Address (Number and Street) Date of Birth (Month / Day / Year)

City, State and Zip or Postal Code Home Telephone Number

Country Personal Email( At least one UNIQUE e-mail REQUIRED)

Employer Data

Employer Work Telephone Number

Employer’s Address (P.O. Box or Number andStreet)

Business Email (Unique e-mail – not shared)

City, State and Zip or Postal Code Cell Phone Number

Country



510 recert (rev) 01/2012 3

Additional Information_______________________________API 510, Pressure Vessel Inspector Certification Program

1. Mailing and Directory Addresses -- Please check the appropriate boxes regarding yourpreference for mailing and directory addresses. Please be sure to check one box only foreach question.

At which address do you wish to receive your certificate? Home Work

Are you interested in being included in the on-line API Inspector

Directory, when you obtain your certification?Yes No

Which address do you want shown in the ICP Directory listing? Home Work

2. Do you currently have any other active API certifications? Yes No

If yes, enter your certification number and expiration date.

653 Certification Number Expiration Date

570 Certification Number Expiration Date

936 Certification Number Expiration date

OTHER Expiration Date

3. Are you currently a fu ll -time, non-cont ract employee ofan API member company?

Yes No

If yes, please enter the company name.

For applicants of the API Individual Certification Programs a discount is offered to the applicant ifhe/she is a full-time and permanent employee of a company currently paying membershipdues to the American Petroleum Institute.

If your company is not a dues-paying member you must pay the non-member price.

4. Please check the boxes that correctly describe your organization type.

What industry do you work for? Are you a ful l-t ime employee of:

PETROLEUM A N OWNER /USER AS DEFINED IN API 510

CHEMICAL I NSPECTION AGENCY

PULP/PAPER I NDIVIDUAL CONTRACTOR

OTHER CONSULTING/CONSTRUCTION



510 recert (rev) 01/2012 4

Inspection Employment History

API 510, Pressure Vessels Inspector Certification Program

Please provide information for the last three years)

1. Name and Address of Employer (Current) Date of Employment

EmployerFrom: ____________________

Mailing Address (Number and Street)To:

____________________

City, State and Zip Code ____________________

Employer’s Telephone

Job Title/Brief Descript ion

2. Name and Address of Employer Date of Employment

EmployerFrom:

____________________


____________________




3. Name and Address of Employer Date of Employment

EmployerFrom:

____________________


____________________




___________________________________________________________________________________

___________________________________________________________________________________



510 recert (rev) 01/2012 5

Verification Requirements for

Employment Reference Forms ERF)

Al l paperwork document ing the appl icant ’s work exper ience MUST be or ig inaldocuments. Photocopied, scanned, or faxed documents will not be processed.

The Employment Reference Form attached to this application must verify that youcontinued to perform inspection-related work over the last three years. Please makecopies of the ERF and provide one form for each employer if it is necessary to meet therequirements.

API requires that the supervisor signs any ERF that is submitted. Supervisors may onlysign for the experience acquired while at their company. This signature must bevalidated by a notary public, Commissioner of Oaths or similarly licensed official. API

requires proof of the validating authority such as a notary stamp, a copy of the license,etc.

Al ternat ive Method of ERF Verif ication

If a notary is not available in your country then ALL THREE OF THE FOLLOWINGREQUIREMENTS MUST BE MET to complete and verify the documentation of youremployment:

1. The ERF must be signed by a supervisor.

2. The ERF must be stamped with a company stamp instead of the notary stamp.

3. In addition to the ERF the applicant must provide an “employment confirmation

letter”. This letter must be submitted on company letterhead, and signed by an

individual other than your supervisor - a higher company official such as

department manager, director, vice-president. The letter must confirm that the

applicant is employed in an inspector capacity and include a detailed description

of the job responsibilities.



510 recert (rev) 01/2012 6

Employment Reference Form (ERF) for RecertificationAPI 510, Pressure Vessels Inspector Certification program

Note: This form applies to API 510 only and must cover at least 20% of the last three years of theinspector’s work experience. This time must have been spent as an inspector using the practicesoutlined in API Standard 510.

Applicant’s Name:

510 Certification Number

Company:

Address Telephone Number

Name of Supervisor Title

Affirms that

Name of Applicant

worked for

Company

FromBeginning Date

toEnding Date

__________________________________________________________________________________________ _

ALL APPLICANTS MUST HAVE THE AREA BELOW COMPLETED AND NOTARIZED

I, the undersigned, confirm, that __________________________ has been employed in a capacity of

Certified Inspector under API Standard 510 during the period stated above.

SUPERVISOR’S NAME (PLEASE PRINT) ________________________________

Supervisor's Signature ________________________________Date_________________________

Subscribed and sworn to before me the ___________________ day of ________________, ______.

______________________________________________________

Notary’s Siganature

My commission expires _________________________. Notary Public Notary or Company

Stamp or Seal



510 recert (rev) 01/2012 7

Inspector Recertification Agreement -- 1

(Effective on Date of Inspector’s Certification)

This Agreement is between the American Petroleum Institute (hereinafter “API”), a corporation of the District ofColumbia, having an office at 1220 L Street, N.W., Washington, D.C. 20005, and the Applicant (the “Inspector”),residing at the address noted below.

Whereas, API’s Individual Certification Programs (“ICP”) certify inspectors and other technical personnel thatmeet the guidelines and requirements specified in the program.

Whereas, Inspector desires to obtain certification under the API ICP program.

Now therefore, in consideration of the mutual covenants hereinafter stated, the parties agree as follows:

1. Inspector agrees to comply with all of the program policies and requirements. Inspector agrees andunderstands that API shall be the sole judge or whether the Inspector has the appropriate qualifications tobecome certified, remain certified, or to be recertified.

2. The Inspector agrees not to make any misrepresentations concerning the Inspector’s certification status orthe program. The Inspector agrees not to perform any acts, which directly or indirectly assist a third-party inmaking any misrepresentation relating to the ICP program.

3. The Inspector understands and agrees that the ICP Program is designed to assist users in identifyinginspectors who have satisfied the minimum qualifications specified in the applicable industry standards andthat API does not warrant or guarantee the competency of any inspector certified under this program. Theinspector agrees not to mislead customers or the public about the scope and purpose of this program.

4. The Inspector authorizes API to release information to regulatory agencies, current or potential employers, orother interested parties concerning the inspector’s certification status. API agrees to take reasonablemeasures to ensure that any information that is released is accurate. However, API does not warrant orguarantee the accuracy of any information that is released and specifically disclaimers any liability relating tothe release of this data.

5. The Inspector understands and agrees that the Inspector’s certification will not be renewed unless theinspector satisfies all of the program requirements for renewal and submits the appropriate recertificationapplication and renewal fee to API within the time frame specified by API.

6. Inspector understands and agrees that API may modify the requirements for an inspector to obtain, maintain,

or renew the certification at any time. If API’s requirements are modified, API shall determine the date bywhich the new requirements become effective. Inspector agrees to comply with the modified requirementswithin the deadline specified by API. API agrees to attempt (but assumes no duty) to notify Inspector ofsignificant changes to the program by either giving notice: (1) at the Inspector’s last known address, or (2)the Inspector’s last known e-mail address, or (3) by posting the changes on the API website. It is theresponsibility of the Inspector to notify API of address changes. The failure of API to notify Inspector of arenewal date or modification of the program does not relieve the Inspector of the responsibility to file a timelyrenewal application or to comply with new certification requirements. It is the responsibility of the Inspectorto obtain this information by contacting API or by checking the API website for updates.

7. If any action or proceeding is brought by API to enforce, protect or establish any right or remedy with respectto this Agreement or with respect to the subject matter of this Agreement, API shall be entitled to recoverreasonable attorney's fees and costs provided that it is the prevailing party. Inspector agrees to indemnify

API for any losses or damages resulting from the breach of the terms of this Agreement by the Inspector.

8. The Inspector agrees and understands that API may terminate an inspector’s certification if API determinesthat the inspector has: (1) made material errors, omissions, or misrepresentations on the application or indocuments submitted to API, or (2) violated any terms or conditions of this Agreement or any ICP policies orrequirements. API also may terminate the program at any time and for any reason deemed appropriate by

API. Upon termination, with or without cause, of any rights or authority conferred by this Agreement, or uponexpiration/termination of the Inspector’s certification, Inspector agrees to return all certification documents to

API within 30 days.

9. The Inspector shall not use any trademark of API or name of API including any abbreviation thereof, in anypublicity, advertising, or for other promotional purposes without the prior written approval of API.



510 recert (rev) 01/2012 8

10. The Inspector agrees to comply strictly with all U.S. export laws relating to this program. The Inspectorwarrants that he is not located in, or under the control of, or a national or resident of any embargoedcountries.

11. This agreement shall not and is not intended to benefit or to grant any right or remedy to any person or entitythat is not a party to this Agreement.

12. This instrument contains the entire and only agreement between the parties. No oral statements orrepresentations not herein contained shall have any force and effect.

13. Paragraphs 2, 3, 4, 5, 6, 7, and 8 survive termination of this agreement.

14. It is expressly understood between the parties hereto that no association, agency, apparent agency,employer/employee relationship, partnership, or joint venture of any kind has been created. Inspector agreesnot to refer to himself as API’s agent nor refer to the relationship between the parties as a joint venture orpartnership or any in manner inconsistent with this Agreement. Inspector shall have no authority to act orcontract on behalf of API.

15. No waiver API of any default, misrepresentation, or breach of warranty or covenant hereunder, regardless ofwhether intentional, shall be deemed to extend to any prior or subsequent default, misrepresentation, orbreach of warranty or covenant hereunder or affect in any way any rights arising by virtue of any prior orsubsequent such occurrence.

16. API makes no express or implied warranties regarding the ICP program or potential benefits of thecertification to the Inspector.

17. The Inspector agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed byany government body or authority based on in any way measured by this Agreement, or any portion or it, orany services related thereto.

18. Inspector understands and agrees that Inspector is not granted any rights under the program or this Agreement until API has determined that the Inspector has satisfied all of the program requirements and hasissued a Certificate to the Inspector. The Inspector’s certification shall be effective on the date that is notedon the Certificate and shall be effective for a period of three years unless terminated pursuant to the terms ofthis Agreement.

19. This Agreement shall be governed by and construed in accordance with the laws of the District of Columbia,USA, without regard to the rules regarding conflicts of law. The parties agree that any action, suit, orproceeding based upon any matter, claim, or controversy arising hereunder or relating hereto shall bebrought exclusively in the federal or state courts located in District of Columbia, USA. The parties consent to

the jurisdiction and venue of such courts, and waive any objections to the jurisdiction and venue thereof.

I, the undersigned, certify that I have read and full y comprehend th is form in its entirety and agree tocomply with the conditions specified above.

Applicant’s name (please print) __________________________ E-MAIL__________________________

_____________________ _________________

Signature of Applicant Date

Applicant’s address: ______________________________________________

_____________________________________________

______________________________________________

API Reviewer’s Initials: ____________



510 recert (rev) 01/2012 9

Inspector Application Agreement -- 2

for Renewal Certification)

Effective Upon Receipt of Application)

The applicant agrees to the follow ing conditions :

1. API agrees to evaluate the applicant’s qualifications to determine if the Inspector satisfies therequirements of the ICP program. Applicant understands and agrees that: (1) API will not issue an ICPcertificate to the Applicant unless API determines that an Applicant meets all of the requirements and

Applicant has submitted the applicable fees and documentation within the specified time frame, and (2) API shall be the sole judge of whether the Applicant has the appropriate qualifications to becomecertified, remain certified, or be recertified.

2. The Applicant agrees to pay the applicable fees, comply with all of the program requirements and submitany supplemental information or documents deemed necessary by API to verify an applicant’squalifications. Applicant understands and agrees that API does not represent or warrant that thesubmission of the fees and materials by the Applicant will result in the Applicant being certified under theprogram.

3. For normal processing API must receive recertification applications prior to the current certification’sexpiration date. Recertification applications must be mailed, as API requires the original of the notarizedpage.

4. API may extend the certification term for 3 (three) months after the expiration date. Inspectors will remainauthorized during that period of time. Recertification applications received by API within this extensionterm will be processed, but a $150 late fee will be required.

5. Inspectors who do not apply for recertification within three months after the current certification expirationdate will be decertified.

6. Circumstances such as heavy work schedule or work in other countries do not relieve the applicant of theresponsibility to file a timely renewal application.

7. Applicant understands and agrees that API may modify the requirements for an applicant to obtain,maintain, or renew the certification at any time. If API’s requirements are modified, API shall determinethe date by which the new requirements become effective. Applicant agrees to comply with the modifiedrequirements within the deadline specified by API. API agrees to attempt (but assumes no duty) to notify

Applicant of significant changes to the program by either giving notice: (1) at the Applicant’s last knownaddress, or (2) the Applicant’s last known e-mail address, or (3) by posting the changes on the APIwebsite. It is the responsibility of the Applicant to notify API of address changes. The failure of API tonotify Applicant of a renewal date or modification of the program does not relieve the Applicant of the

responsibility to file a timely renewal application or to comply with new certification requirements. It is theresponsibility of the Applicant to obtain this information by contacting API or by checking the API website

8. The Applicant agrees to comply strictly with all U.S. export laws relating to this program. The Applicantwarrants that he is not located in, or under the control of, or a national or resident of any embargoedcountries.



510 recert (rev) 01/2012 10

9. The Applicant agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed byany government body or authority based on in any way measured by this Agreement, or any portion or it,or any services related thereto.

10. Applicant warrants and represents to all information that is being submitted pursuant to this is completeand accurate. Application understands that API is relying upon the accuracy of this information inevaluating the Inspector’s qualifications. Applicant agrees to indemnify API for any claims, losses, or

damages resulting from the Applicant submitting inaccurate or misleading information.

I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agree to

abide by the policies and regulations specified above.

__________________________________________ ___________________

Signature of Applicant Date

E-MAIL address (please print)____________________________________

API Reviewer’s Initials: ________________



510 recert (rev) 01/2012 11

API 510 Recertification Fees

Applicant’s Name _______________________________

API member rate appl ies to full -time, non-cont ract employees of API-member companies.

API Member Non Member

RE-CERTIFICATION FEE $500 $650

PAYMENT INSTRUCTIONS

All payments must be made in United States currency. Checks must be drawn on a U.S. bank. You are responsible for all taxes, banking or other service fees,

including all applicable withholding taxes. Appl icant ’s name(s) must be included on the check. For payments by electronic transfer: (1) you are responsible for all electronic transfer, A.C.H. and

banking fees (be sure to add the fees to your payment); (2) for electronic payments not drawn on a U.S.bank a fifty-dollar ($50) handling fee must be added at the time payment is made.

Please include a copy of the wire / electronic transaction. Appl icant ’s name(s) must be

included on the transaction document.

PAYING BY CREDIT CARD COULD EXPEDITE PROCESSING OF YOUR APPLICATION

Credit Card Type: Visa American Express MasterCard

Card Number: Expiration Date:

Name as it appears on card _____________________________________________

Signature _______________________________________

E-mail address to send receipt: Re-Certification Fee

Check # Penalties / Other

Bank Fee (if wired)

Wire Transfer to:TOTAL SUBMITTED

TD Bank1030 15th St NWWashington, DC 20005 USA

ABA Routing # 054001725Credit to: American Petroleum Institute

Account # 4251303172 SWIFT: NRTHUS33(Reference: Applicant’s Name and SS-2100-D9200-7110)

Your application will not be processed if this page is not completed.



510 recert (rev) 01/2012 12

CHECKLIST

1. All pages of the application completed

2. Valid e-mail address included so we can contact you

3. ERF has a notary or company stamp

4. Employment letter attached if necessary

5. BOTH Inspector Agreement forms signed

6. Re-certi fication Fee (and late fee if appl icable)

7. Copy of transaction documentation if paying by wire

8. Copy of completed application made for your records

MAIL ORIGINAL APPLICATION TO: APIIndividual Certification Programs1220 L Street, NWWashington DC 20005

(Phone: 202-682-8064)Please include candidate’s name(s) on all payments.

IF PAYING BY CHECK OR MONEY ORDER, MAIL APPLICATION TO: APIIndividual Certification ProgramsP.O. Box 1425

Merrifield, VA 22116

TO SEND CHECKS BY COURIER, PLEASE ADDRESS PACKAGE TO:

API At tn: John Rober tson1220 L Street, NWWashington, DC 20005Phone 202-682-8064

Documents

510-Recert-App_01-2012_revised2