357020252-CWB-INWC-Reciprocity-Application-2461

CWB/INWC Reciprocity Application_2461 Page 1 of 2 June 15, 2017 8669 NW 36 St, #130 Miami, FL 33166-6672 (800) 443-9353 extension 273 Initial/ Renewal Reciprocity Application CWB/ICWI to CWI AWS Membership # ____________________________ Last Name First Name MI Address (c ont'd) Apt # City and State / Province / Country Zip Code Home Telephone Number Work Telephone Number Mobile Telephone Number E-Mail Address (confirmation notification will be sent to this address) Date of Birth ( example November 30 1952) 1. Choose one 1 st Time Reciprocity Reciprocity Renewal CWI Certification # ___________________________ Expiration Date ______________ CWB Applicants : Attach a copy of your CWB card with a current expiration date confirming your certification to Canadian Standard CSA W178.2. ICWI Applicants : Attach a copy of your ICWI card with a current expiration date confirming you successfully passed the INWC examination 2. Visual Acuity Record A current Visual Acuity Record must be completed and submitted with this application. To download a copy of the form, visit our website . 3. Photo Requirement Applicants MUST submit one (1) passport-style color photograph. Your photo is a vital part of your application. To learn more, review the information on how to provide a suitable photo to avoid processing delays by visiting our website . The acceptance of your photo is always at the discretion of the AWS. Print your name and AWS membership number on the reverse of the photograph. 4. Method of Payment Fees AWS USE ONLY Payment must accompany this application. AWS Bank Information - All checks, Demand Drafts and money orders must be drawn against banks in U.S.A., payable in American Dollars and made payable to American Welding Society . Acct #: ___________________________________ Check or money order #_______________________ VISA MC AMEX Discover Date: ____________________________________ CC#: / / / Exp: / SIGNATURE: _________________________________________________________ CVV:______________________ Amt $: ___________________________________ Faxed or emailed applications are NOT accepted Month Day Year Photos copied or digitally scanned from driver's licenses or other official documents are not acceptable . Print your name and AWS membership number on the reverse of the photograph. Only use scotch tape on the back of the photo.

Name ________________________________________________ AWS Member # _________________________________ CWB/INWC Reciprocity Application_2461 Page 2 of 2 June 15, 2017 5. Testimonial Certified Welding Inspector QC1 Standard for the AWS Certification of Welding Inspectors B5.1 Specification for the Qualification of Welding Inspectors Applicants must read and sign the following statement in front of a notary I hereby certify that I have read the standard requirements contained in the certification programs indicated above. Further, I agree to comply with the existing requirements and any subsequent requirements that may be instituted by AWS. I have read and agree to the terms and conditions set forth in the AWS Policies and Fees form. I certify that the information I have included on this application is true. I understand that any false statements will nullify this application. I give AWS permission to verify this information. I agree to comply with the provisions set forth in the Standard concerning the administration of my examination and certification. Upon obtaining my certification, I give AWS the right to reveal my certification status as it relates to my validity and expiration date only. I further understand that any required information that is incomplete or missing will cancel this registration. Furthermore, I certify that I have not obtained or shared any exam materials, have no prior knowledge of the AWS exam questions or answers, and have not and will not accept any solicitation for the AWS exam questions or answers from anyone at any time before or after the exam. I understand that a violation of this oath may be grounds for invalidation of my certification. Applicant's Signature ______________________________________________________ Date _________________________ The following is to be completed by A Notary Public Sworn to and subscribed before me this __________ day of ___________________ 20 _____ . My commission expires _________________________________________________________ Notary Public Signature _________________________________________________________ NOTARY STAMP AND/OR SEAL IS REQUIRED