API 936 Certification Program Refractory Personnel

Examen en Junio/ Diciembre de 2012, en ARGENTINA Toda la documentación y pagos para la inscripción al examen deben enviarse a:

TEDUC

Av. Roque Sáenz Peña 615, Of. 611 (C1035AAB) Buenos Aires, Argentina

Tel/Fax.: (005411) 4326-1404/ 4328-4459

Consultas: sabino@teduc.com.ar www.teduc.com.ar

FECHAS LÍMITE PARA EL EXAMEN – ARGENTINA

Fecha de Examen Fecha límite de aplicación y pago Fecha límite para solicitar re-examen

6 de Junio de 2012 Pago: 14 de Febrero Entrega de Doc: 22 de Febrero 22 de Febrero

5 de Diciembre de 2012 Pago: 10 de Agosto Entrega de Doc: 17 de Agosto 17 de Agosto

- Deberá completar y enviar a TEDUC, en sobre cerrado, la aplicación para el examen

(original), junto con la documentación pertinente, antes de la fecha límite de aplicación. No se aceptarán aplicaciones por fax o mail.

- Enviar el pago a TEDUC. Completar y enviar por correo, mail (sabino@teduc.com.ar ) o fax (0054-11-43261404), la solicitud de pago antes de la fecha límite. Si Usted ha realizado el pago por transferencia bancaria, por favor, enviar comprobante del mismo por mail o por fax.

- Para re-inscripciones completar y enviar la solicitud de pago (página 1.2), con el comprobante de pago correspondiente y completar y re-enviar página del aplicativo (REQUEST FOR FOREIGN LANGUAGE EXAMINATION).

1.1

mailto:sabino@teduc.com.arhttp://www.teduc.com.armailto:sabino@teduc.com.ar

Nombre del Candidato: API 936 - Solicitud de Pago La tasa para miembro API aplica para el personal en relación de dependencia de empresas miembro API, no para personal contratado/subcontratado.

Miembro API No Miembro

U$S 350.00 U$S 500.00

INSTRUCCIONES DE PAGO – Examen en ARGENTINA • Todos los pagos deben realizarse en TEDUC. Incluir u$s110 por gastos administrativos y de gestión. Valor neto

a transferir: Miembro API u$s460/ No Miembro u$s610. Para re-inscripción incluir u$s30 (Neto u$s180)

• Los pagos deben ser realizados antes de la fecha límite de inscripción. • Cheques deben estar emitidos a la orden de TEDUC S.R.L. Usted será responsable por el pago de impuestos. • Transferencia Bancaria: Debe ser realizada a la cuenta indicada y Usted será responsable por los gatos de

transferencia.

• Complete y entregue la solicitud de pago. Envíe comprobante de pago en caso de transferencia bancaria. INDIQUE FORMA DE PAGO

Pago por Inscripción (U$S460/ U$S610 + IVA)

Pago por Re-inscripción (U$S 180 +IVA)

CHEQUE/EFECTIVO

Nro. Cheque:

Bco.:

TRANSFERENCIA Datos para transferencia: Razón social: TEDUC S.R.L Cuit: 30-70851313-6 Banco de la Nación Argentina - Sucursal Villa del Parque (N° 94) Cuenta Corriente: 2400105-72 CBU 01100242-20002400105721 Recuerde agregar en su pago los gastos de transferencia. Envíe comprobante de pago por mail a administracion@teduc.com.ar o por teléfono/fax llamando al (0054-11) 4328-4459/ 4326-1404.

TARJETA DE CRÉDITO (Consulte recargos por pago con tarjeta)

Tipo de Tarjeta: VISA MASTERCARD

N° Cuotas

Datos de la Tarjeta

Nombre(s) Apellido(s)

Número de Tarjeta Código de Seguridad

Vencimiento DNI

Domicilio Teléfono

Datos de Facturación

Nombre/Apellido o Razón Social Cuit

Dirección Teléfono

1.2

mailto:administracion@teduc.com.ar

API 936 Refractory Personnel Certification Program

Instrucciones para el Aplicativo. 1. Este aplicativo es un archivo PDF se puede escribir. Por favor, asegúrese de descargar el documento y guardarlo en su computadora. A continuación, puede abrir la aplicación, escriba su información en el mismo PDF, e imprima el aplicativo. (Cualquier Aplicativo que se complete en línea no se guardará, deberá descargarlo a su PC para completarlo). Deberá enviarlo impreso y con todas las firmas en original a TEDUC. 2. Complete todas las páginas de esta solicitud. 3. Por favor escriba su nombre tal como aparece en su pasaporte / documento oficial de identidad / licencia de conducir. 4. Si ya ha aplicado a API y tiene asignado un número de identificación (ID) de API, se deberá incluir en todos los lugares donde aparece su nombre. 5. Asegúrese de incluir una única y actual dirección de correo electrónico. Toda la correspondencia de API, incluyendo su carta de admisión y el informe de calificación del examen, será enviada a la dirección de correo electrónico que usted proporcione. 6. Tome nota de los documentos de estudio que se enumeran en la hoja de Publications Effectivity Sheet. Los códigos para los exámenes de certificación de ICP pueden obtenerse a través de IHS (www.global.ihs.com) o TechStreet (www.techstreet.com). 7. La página 5 debe completarse con los últimos tres trabajos que haya realizado. Desde el más reciente, hasta el más antiguo, respectivamente. 8. En la página 6, haga una marca en la fecha que desea realizar el examen. Para indicar el lugar donde desea presentar el examen, escriba la ciudad y país donde figura API-approved special site (si no encuentra en el listado de países el lugar). 9. Leer y firmar los dos Acuerdos del Inspector y la página de FOREIGN LANGUAGE WAIVER. Recuerde colocar, en esta última, en la opción idioma la leyenda “en español e Inglés” para recibir el examen en ambos idiomas. 10. En la página 16 deberá indicar lo siguiente: en la primera pregunta si usted ha realizado un curso preparatorio para rendir el examen y el nombre del proveedor del curso. En la segunda pregunta debe indicar si los códigos que lleva al examen fueron provistos por el proveedor del curso. De no ser así deberá colocar como obtuvo los códigos. En la última parte de la pagina (Include proof of legal purchase) deberán indicar la proveniencia de los códigos originales que llevará al examen; a. Colocar el ID de la empresa en la cual trabaja, que les facilita los códigos, (no podrá colocar el ID de una empresa de la cual no es empleado), b. Indicar el numero de factura en el caso de que haya comprado el código, c. indicar otras formas de obtención de los códigos.

http://www.global.ihs.com)http://www.techstreet.c

API 936 Refractory Personnel Certification Program

11. Realizar el Pago. Vea la página 1.2 de Solicitud de Pago. No se tramitará ninguna solicitud hasta que se reciba el pago. La página 1.2 remplaza a la página 11 del aplicativo, por tal motivo sólo deberá completar la página 1.2. 12. Asegúrese de guardar una copia de la Aplicación completa que usted envíe, incluyendo copias de su ERF, diplomas, carta del empleador, etc. 13. Cuando haya completado su solicitud, revise la lista en la parte posterior del aplicativo, para asegurarse que ha incluido toda la información y los documentos necesarios. Recuerde que el aplicativo original debe ser enviado a TEDUC, por tal motivo deberá omitir la información posterior con dirección de API.

TEDUC SRL

Av. Roque Sáenz Peña 615, Piso 6, Of. 611 (C1035AAB) Ciudad Autónoma de Buenos Aires - Argentina

Tel: (54-11) 4328-4459 - Tel/Fax: 4326-1404 INFORMACIÓN PARA EL DÍA DEL EXAMEN: • Se le permite tener sólo lo siguiente en la sala de examinación: Los códigos API originales y permitidos, lápiz No. 2, una goma de borrar y una calculadora (simple, no programable). Cualquier otro elemento podría ser confiscado por el personal que tome el examen. • Cualquier material adicional a los de referencia no están permitidos. Esto incluye los materiales de capacitación, las páginas insertadas en los libros de códigos, etiquetas pre-impresas incorporadas a los códigos, páginas en blanco de escritura (a mano o en el medio de los libros de códigos). • Las pequeñas notas en los márgenes están permitidas. Ante cualquier consulta no dude en contactarse con TEDUC.

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API 936 Refractory Personnel Certification Program Application Instructions

1. This application is a writable PDF. BE SURE to download the document and save it on your

computer, before filling it out. Open the saved application, type in your information, and print the application forms to be mailed to API. (Any application filled in while viewing it online will not be saved, nor will it be sent to API electronically.) All original 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 / govt-issued ID / driver’s license.

4. If you have previously applied to API and been assigned an API ID number, include it every place

that your name appears in the application 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. Make note of the applicable documents to study as listed on the Publications Effectivity Sheet.

The publications for ICP certification exams may be ordered through IHS (www.global.ihs.com) or TechStreet (www.techstreet.com)

7. Read and sign BOTH Inspector Agreements

8. Include the certification fee. See Page 2 for ICP Financial Policies. We will not process any

application until full payment is received.

9. Be sure to keep a copy of the completed application that you mail to API.

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

INFORMATION FOR THE DAY OF THE EXAM: You are allowed to have only the following in the test room: Sharpened No. 2 pencils, an eraser and a calculator (simple function only, non-programmable). Anything else could be confiscated by the test staff.

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ICP FINANCIAL POLICIES

Payment Policy API cannot process any application until full payment is received. No exceptions will be made under any circumstances. Candidates WILL NOT BE PERMITTED TO TAKE AN ICP EXAMINATION if payment has not been received AND processed by API. Proof of payment must be included with your application. API must RECEIVE your ORIGINAL application by mail on or before the application

deadline. All payments must be made in United States currency. Paying by credit card provides the best opportunity to ensure that payment is received and

processed by API in the timeliest manner. Checks must be drawn from a US bank. You are responsible for all taxes, banking or other

service fees, including all applicable withholding taxes. If your company is going to pay the fee make sure they know the deadline and allow plenty

of time for the company to make payment.

If paying by wire transfer please submit a copy of the electronic transaction document with your application. The applicant’s name MUST be included on the wire transaction document. If the copy is not included with the application please e-mail a copy to inspector@api.org as soon as possible to allow time to identify the payment and schedule you for the exam.

Refund Policy

All requests for refunds must be submitted to API in writing by mail, e-mail or fax and requested within 6 months of the date of the payment.

For refund requests made before the application deadline: API will refund the initial certification fee less $100.00 for processing.

For refund requests made after the application deadline: API will refund 50% of the initial certification fee. Reschedule fees are non-

refundable. For refund requests made after the date of your examination:

No refunds will be issued whether you took the examination or not.  

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Application Form – Basic Information API 936, Refractory Personnel Certification Program

New – API Exam EXAM ID # (if previously assigned)

___________________________________________________________________________________________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 Work Telephone Number

Employer Business Email (Unique e-mail – not shared)

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

Cell Phone Number

City, State and Zip or Postal Code If you want your exam admission letter / score report to be sent to your employer, trainer, or exam organizer, please include this person’s e-mail here:

Country Group Contact E-mail

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Additional Information API 936, Refractory Personnel Certification Program

1. Mailing and Directory Addresses -- Please check the appropriate boxes regarding your preference for mailing and directory addresses. Please be sure to check one box only for each 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 an active API certification? Yes No

If yes, enter your certification number and expiration date.

Program / Certification Number Expiration Date

Program / Certification Number Expiration Date

Program / Certification Number Expiration Date

3. Are you currently a full-time, non-contract employee of an API member company?

Yes No

If yes, please enter the company name.

4. Please check the boxes that correctly describe your organization. Please be sure to check one box on each side.

Industry Organization type

PETROLEUM OWNER-USER

CHEMICAL INDIVIDUAL CONTRACTOR

PAPER/PULP INSPECTION COMPANY

SERVING ALL INDUSTRIES CONSULTING/CONSTRUCTION

OTHER OTHER

5. Please check the boxes that correctly describe your employment status. Please be sure to check one box only.

Full-time employee of an owner/user

Full-time employee of an inspection agency/other company

Independent contractor

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Employment History API 936, Refractory Personnel Certification Program (Last three employers or at least the last five years)

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

Employer From:

____________________

Mailing Address (Number and Street) To:

____________________

City, State and Zip Code

Job Title / Detailed Description of Responsibilities

2. Name and Address of Employer Date of Employment

Employer From:

____________________

Mailing Address (Number and Street) To:

____________________

City, State and Zip Code

Job Title / Detailed Description of Responsibilities

3. Name and Address of Employer Date of Employment

Employer From:

____________________

Mailing Address (Number and Street) To:

____________________

City, State and Zip Code

Job Title / Detailed Description of Responsibilities

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API 936 Test Registration Applicant’s Name: _________________________________________ Exam ID # (If previously assigned): Examination Locations and Dates

Please indicate your preferred exam date and location listed below.

December 5, 2012 (Application Deadline – API must receive no later than September 17, 2012)

June 5, 2013 (Application Deadline – API must receive no later than March 20, 2013)

Application deadlines are firm — no exceptions will be made.

*NOTE: An additional sitting fee will be required at the Edmonton location in December. You will receive information, prior to the exam date, from ABSA / API, with payment instructions. North America:

Anchorage, AK * Edmonton, AB (Canada) Oakland, CA

Atlanta, GA Houston, TX Oklahoma City, OK

Baton Rouge, LA Indianapolis, IN Philadelphia, PA

Corpus Christi, TX Los Angeles, CA

Other Locations:

Abu Dhabi, UAE Chennai, India Kuala Lumpur, Malaysia

Safat (Kuwait City), Kuwait

Al-Khobar, Saudi Arabia Chia, Colombia Mumbai, India Singapore, Singapore

Cairo, Egypt Doha, Qatar Port of Spain, Trinidad

United Kingdom (contact API for city info)

If a location of your choice is not listed above please contact API for more information. If you are testing at an API-approved special site, please include the location and/or

group here:_________________________________________ City, Country

> > THIS FORM MAY ALSO BE USED TO RESCHEDULE A TEST

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FOREIGN LANGUAGE WAIVER for ICP CERTIFICATION EXAMS OUTSIDE OF UNITED STATES

(Complete this form only if testing in a language other than English.) Please complete and sign the form below to take the API exam in a Foreign Language. This form is sufficient for all your attempts within a given program until you obtain your certification. If you do not submit this form, or the form is incomplete, you will take the exam in English. Please note: Translations are not available for all languages or all programs, and API does not guarantee that your requested translation will be available. Make sure to visit the API website and confirm language availability prior to applying. I, ________________________________________________________ ID # ____________________ (Please print your full name above. If you hold another certification with API please include that number),

request to take the following examination in a foreign language:

API program: _______________________________________

Location: ___________________________________________

Language requested: __________________________________

Assumption of the Risk and Waiver of All Claims

Read this carefully before signing. Translation of technical terminology and complex subjects is difficult and subjective. API cannot warrant that the foreign language translations of API materials are accurate. By signing this form, you agree to assume any risk of inaccurate translations and also to waive any claim against API related to the accuracy of the translated exam. I, the undersigned, agree to the following:

1. I agree to take the API __________ examination in a foreign language. I understand that the technical translation of the terminology in the course of the examination may or may not be familiar and acceptable to me.

2. In the event of my failing the examination I agree to hold API harmless against any claims related to the language of the examination.

3. In the event of my failing or not taking the examination I understand and agree that API will not make any refunds of my application fees or be liable for any damages whatsoever.

4. API shall be the sole judge or whether I have the appropriate qualifications to become certified under API Individual Certification programs.

Signature: ____________________________________________

Full name: _____________________________________________

Company Name: ________________________________________

Date: ______________________________________________

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Inspector Certification Agreement - 1 (Effective on Date of Inspector’s Certification) This Agreement is between the American Petroleum Institute (hereinafter “API”), a corporation of the District of Columbia, 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 that meet 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 and understands that API

shall be the sole judge of whether the Inspector has the appropriate qualifications to become certified, remain certified, or to be recertified.

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

3. The Inspector understands and agrees that the ICP Program is designed to assist users in identifying inspectors who have satisfied the minimum qualifications specified in the applicable industry standards and that API does not warrant or guarantee the competency of any inspector certified under this program. The inspector 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, or other interested parties concerning the inspector’s certification status. API agrees to take reasonable measures to ensure that any information that is released is accurate. However, API does not warrant or guarantee the accuracy of any information that is released and specifically disclaims any liability relating to the release of this data.

5. The Inspector understands and agrees that the Inspector’s certification will not be renewed unless the inspector satisfies all of the program requirements for renewal and submits the appropriate recertification application 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 by which the new requirements become effective. Inspector agrees to comply with the modified requirements within the deadline specified by API. API agrees to attempt (but assumes no duty) to notify Inspector of significant changes to the program by either giving notice: (1) at the Inspector’s last known e-mail address, or (2) by posting the changes on the API website. It is the responsibility of the Inspector to notify API of address and e-mail changes. The failure of API to notify Inspector of a renewal date or modification of the program does not relieve the Inspector of the responsibility to file a timely renewal application or to comply with new certification requirements. It is the responsibility of the Inspector to 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 respect to this Agreement or with respect to the subject matter of this Agreement, API shall be entitled to recover reasonable 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 determines that the inspector has: (1) made material errors, omissions, or misrepresentations on the application or in any other documents submitted to API, or (2) violated any terms or conditions of this Agreement or any ICP policies or requirements. 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 upon expiration/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 any publicity, advertising, or for other promotional purposes without the prior written approval of API.

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

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

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12. This instrument contains the entire and only agreement between the parties. No oral statements or representations 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 agrees not to refer to himself as API’s agent nor refer to the relationship between the parties as a joint venture or partnership or in any manner inconsistent with this Agreement. Inspector shall have no authority to act or contract on behalf of API.

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

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

17. The Inspector agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by any government body or authority in any way measured by this Agreement, or any portion of it, or any 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 has issued a Certificate to the Inspector. The Inspector’s certification shall be effective on the date that is noted on the Certificate and shall be effective for a period of three years unless terminated pursuant to the terms of this 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, or proceeding based upon any matter, claim, or controversy arising hereunder or relating hereto shall be brought 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 fully comprehend this form in its entirety and agree to comply with the conditions specified above.

Applicant’s name (please print) _____________________________ E-mail: _________________________ ___________________________________ _________________ Signature of Applicant Date Applicant’s address: ______________________________________________ ______________________________________________ API Reviewer’s Initials: ____________

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Inspector Application Agreement - 2 (for Initial and Renewal Certification)

(Effective upon Receipt of Application) The applicant agrees to the following conditions:

1. API agrees to evaluate the applicant’s qualifications to determine if the Inspector satisfies the requirements of the ICP program. Applicant understands and agrees that: (1) API will not issue an ICP certificate 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 become certified, remain certified, or be recertified.

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

3. Each new application remains valid for a period of 12 months from the date of receipt by API. API grants each applicant three consecutive attempts during the 12-month period to sit and pass the test, starting with the first exam administration the applicant registers for. Applicants must pass the exam within these three consecutive exam administrations. If an applicant fails to appear for the test, cancels his/her appearance and reschedules, or takes the exam and fails it, it will count as an official attempt.

4. If the applicant does not obtain a certification within this period of time and still wishes to obtain the certification, they must start the application process again, including re-submission of a full fee and a complete new application.

5. All requests for refunds must be submitted in writing by mail, e-mail or by fax to API no later than 6 months from the date payment was received by API. Requests for refunds received after this period cannot be fulfilled.

6. An applicant is entitled to a full refund of the application fee, minus a processing fee, only if API receives the refund request prior to the exam application deadline. Reschedule fees are not refundable.

7. An applicant is entitled to a 50% refund of the application fee if the refund request is received by API within 6 months from the date payment was received by API and the candidate cancelled in advance of the examination date.

8. No refunds will be made if an applicant has taken the test or did not show up without prior notice.

9. For normal processing API must receive recertification applications prior to the current certification’s expiration date. Recertification applications must be mailed, as API requires the original of the notarized page.

10. API may extend the certification term for 3 (three) months after the expiration date. Inspectors will remain authorized during that period of time. Recertification applications received by API within this extension term will be processed, but a $150.00 late fee will be required.

11. Inspectors who do not apply for recertification within three months after the current certification expiration date will lose their certification.

12. Circumstances such as heavy work schedule or work in other countries do not relieve the inspector of the responsibility to file a timely renewal application.

13. 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 determine the date by which the new requirements become effective. Applicant agrees to comply with the modified requirements 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 known e-mail address, or (2) by posting the changes on the API website. It is the responsibility of the Applicant to notify API of address changes. The failure of API to notify 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 the responsibility of the Applicant to obtain this information by contacting API or by checking the API website.

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

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

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16. Applicant warrants and represents to all information that is being submitted pursuant to this is complete and accurate. Applicant understands that API is relying upon the accuracy of this information in evaluating 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. Applicant’s name (please print) ____________________________ E-mail: ___________________________ ___________________________________ _________________ Signature of Applicant Date API Reviewer’s Initials ________________

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API 936 - PAYMENT INFORMATION Applicant’s Name: _________________________________________ Exam ID # (If previously assigned): API member rate applies to full-time, non-contract employees of API-member companies.

API Member Non Member $350.00 $500.00

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. Applicant’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. Applicant’s name(s) must be included on the transaction document.

PAYING BY CREDIT CARD CAN EXPEDITE THE PROCESSING OF YOUR APPLICATION AND PAYMENT TO ENSURE YOUR PLACE IN THE EXAMINATION. Credit Card Type: Visa American Express MasterCard

Card Number:

Expiration Date:

Name as it appears on card

_____________________________________________

Signature _______________________________________ Initial Certification Fee

E-mail address to send receipt: Reschedule / Retest Fee ($150.00)

Check Late Penalties

Bank Fee (if wired)

Wire Transfer to: TOTAL SUBMITTED TD Bank 1030 15th St NW Washington, DC 20005 USA ABA Routing # 054001725 Credit 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.

936_newcertapp_2012-2013_final_7-23-12.docx

API 936 Exam Publications Effectivity Sheet FOR: December 5, 2012 and June 5, 2013

Listed below are the effective editions of the publications required for this exam for the date(s) shown above. API Publications API Standard 936; 3rd Edition, Nov 2008 – Refractory Installation Quality Control Guidelines – Inspection and Testing Monolithic Refractory Linings and Materials.

Please ensure you obtain this document from one of API’s authorized redistributors: Techstreet: www.techstreet.com; Phone: 1-800-699-9277

IHS Documents: www.global.ihs.com; Phone: 1-800-854-7179

ACI (American Concrete Institute) Publications: These two documents are currently available as a .pdf file through the ACI bookstore. To access these two titles go to http://www.concrete.org/bookstorenet/. (Type 547.R-87 in “Search” field; then select “ by” Order Code; then “in” Inactive -- both documents should appear) 547.R-87 – State of the art report: Refractory Concrete 547.1R-89 – State of the art report: Refractory plastic and Ramming Mixes ASTM (American Society for Testing and Materials) Publications: C113-02 – Standard Test Method for Reheat Change of Refractory Brick

(Available at http://www.astm.org/Standards/C113.htm) C133-97 – Standard Test Methods for Cold Crushing Strength and Modulus of Rupture of Refractories

(Available at http://www.astm.org/Standards/C133.htm) C181-09 – Standard Test Method for Workability Index of Fireclay and High-Alumina Plastic Refractories

(Available at http://www.astm.org/Standards/C181.htm) C704-01 - Standard Test Method for Abrasion Resistance of Refractory Materials at Room Temperatures (Available at http://www.astm.org/Standards/C704.htm)

936_newcertapp_2012-2013_final_7-23-12.docx

CHECKLIST

1. All pages of the application completed 2. Valid e-mail address included so we can contact you 3. Foreign Language Waiver signed, if necessary 4. BOTH Inspector Agreement forms signed 5. Certification Fee (payment page filled in completely) 6. Copy of transaction documentation if paying by wire 7. Copy of completed application made for your records

IF PAYING BY CREDIT CARD, MAIL ORIGINAL APPLICATION TO: API Individual Certification Programs 1220 L Street, NW Washington DC 20005 (Phone: 202-682-8064) Please include candidate’s name(s) on all payments.

IF PAYING BY CHECK OR MONEY ORDER, MAIL ORIGINAL APPLICATION TO:

API Individual Certification Programs P.O. Box 1425 Merrifield, VA 22116 Note: Couriers do NOT deliver to a P.O. Box.

TO SEND ORIGINAL APPLICATIONS AND CHECKS BY COURIER: PLEASE ADDRESS PACKAGE TO:

API Attn: John Robertson 1220 L Street, NW Washington, DC 20005 Phone 202-682-8064

ALL CUSTOMER SERVICE INQUIRIES MUST BE DIRECTED TO: inspector@api.org

if previously assigned: FIRST: MIDDLE: LAST: Home Address Number and Street: City State and Zip or Postal Code: Country: undefined: Employer: Employers Address PO Box or Number and: City State and Zip or Postal Code_2: Country_2: Date of Birth Month Day Year: Home Telephone Number: Personal Email: undefined_2: Work Telephone Number: Business Email Unique email not shared: Cell Phone Number: Group Contact Email: Expiration Date: Program Certification Number: Expiration Date_2: Program Certification Number_2: Expiration Date_3: If yes please enter the company name: Name and Address of Employer Current: From: Employer_2: To: Mailing Address Number and Street: Job Title Detailed Description of Responsibilities 1: Job Title Detailed Description of Responsibilities 2: Name and Address of Employer: From_2: Employer_3: To_2: Mailing Address Number and Street_2: Job Title Detailed Description of Responsibilities 1: Job Title Detailed Description of Responsibilities 2: Name and Address of Employer_2: From_3: Employer_4: To_3: Mailing Address Number and Street_3: Job Title Detailed Description of Responsibilities 1_2: Job Title Detailed Description of Responsibilities 2_2: ID: API program: Location: Language requested: Full name: Company Name: Date: Applicants name please print: Email: Date_2: Applicants address: undefined_3: API Reviewers Initials: Applicants name please print_2: API Reviewers Initials_2: Email_2: Date_3: Applicants Name: Card Number: Expiration Date_4: Name as it appears on card: Initial Certification Fee: Reschedule Retest Fee 15000: Late Penalties_2: Bank Fee if wired: TOTAL SUBMITTED: Program Certification Number: Radio Button1: OffRadio Button2: OffRadio Button3: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffRadio Button4: OffRadio Button5: OffApplicant's Name: Radio Button6: OffRadio Button7: OffCIty, Country: Program: Print Full Name: Exam ID #: Radio Button8: OffE-mail Receipt: Check Number: Check Box10: OffCheck Box13: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffRadio Button10: OffRadio Button11: OffCheck Box1: OffPago por Inscripción: OffPago por Re-Inscripción: OffCHEQUE/EFECTIVO: OffTRANSFERENCIA: OffTARJETA DE CRÉDITO: OffVISA: OffMASTERCARD: OffN° Cuotas: Nombres: Apellidos: Número de Tarjeta: Código de Seguridad: Vencimiento: DNI: Domicilio: Teléfono Domicilio: Nombre/Apellido o Razón Social: Cuit: Dirección: Teléfono Empresa: