Free APPLICATION FOR EXAMINATION AS APPROVED BOILER INSPECTOR - Tennessee

STATE OF TENNESSEE
DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT DIVISION OF BOILER and ELEVATOR INSPECTION

APPLICATION FOR EXAMINATION AS APPROVED BOILER INSPECTOR
DATE_________________________ I hereby apply for permission to take the examination for a Certificate of Competency as an approved boiler inspector for the State of Tennessee and certify that the following statements are true and correct. Also included with my application is a check for the nonrefundable examination fee of $100.00.
(First Name) (Middle Initial) (Surname)

Address_______________________________________________________________________________ (Street) (City) (State) (Zip Code)

1. Name of Employer_____________________________________________________ 2. Business address with above named employer will be:
(Street) (City) (State) (Date of Birth) (Zip Code)

3. Are you a citizen of the USA?____________

Age__________________________

Note: If born outside the U.S.A. to other than American parents, state whether you are now naturalized or nonnaturalized. 4. Education_____________________________________________________________
(State years completed in grade school, high school, college, degrees obtained)

5. Previous State Examinations Taken________________________________________
(Date) (State) (Grade) (Cert. No.)

6. Outline in detail the experience that you have had that in your opinion will enable you to qualify as an efficient and competent boiler inspector. The minimum requirements are that applicants shall have at least 3 years experience in boiler construction, fabrication, or repair, or practical operating engineer in charge of high pressure steam generating plants, or inspector of steam boilers. No credit is allowed for time spent as an oiler or fireman. Technical education with a degree of Mechanical Engineer from a recognized college shall be allowed two years as the equivalent of practical experience upon submittal of diploma or a photostat copy thereof.
BOILER CONSTRUCTION Employer's Name & Address _________________________________ _________________________________ FABRICATION REPAIR OR WELDING EXPERIENCE Period of Employment Employed as (Nature) From ______to________ From ______to ________ _______________________ _______________________

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Employer's Name & Address

BOILER OPERATING EXPERIENCE Must have been engineer in charge of steam generating plants. Period of Employment Employed as (Nature) From _____To_______ From______To_______ ________________________ ________________________

_________________________________ _________________________________

Employer's Name & Address

PRESSURE VESSEL/BOILER INSPECTION EXPERIENCE Period of Employment Approximate Number of Internal Inspections Made From ______ To________ From ______ To ________ ________________________ ________________________

_________________________________ _________________________________

Signature of Applicant Falsification of any statement in the application is cause for rejection or revocation of Certificate of Competency, if granted. Sworn to and subscribed before me this ______ day of __________________, ________

Notary Public