Certification Commission, Inc. Exam Registration / EVT …

1 EVT Certification commission , Inc. Exam Registration Form Have you ever registered for an EVT Certification exam before? Yes |__| No |__| xxx- xx - |__|__|__|__| |__|__|__|-|__|__|__|-|__|__|__|__| |__|__|__|-|__|__|__|-|__|__|__|__|Last 4 Digits of Social Security # Home or cell phone Work Phone |__|__|__|__|__|__|__|__|__|__|__|__|__| __|__||__|__|__|__|__|__|__|__|__|__| |__|Last Name First Name MI|__|__|__|__|__|__|__|__|__|__|__|__|_ _|__|__|__|__|__|__|__|__|__|__|__|__|Ho me Address or Box Number|__|__|__|__|__|__|__|__|__|__|__| __|__|__|__|__|__|__| |__|__| |__|__|__|__|__|__|__|__|__|__|City State Zip or Postal CodeConfirmation Letter will be emailed Email:|__|__|__|__|__|__|__|__|__|__|__| __|__|__|__|__|__|__|__|__|__|__|__|__|_ _|__|__|__|__|Date of Birth |__|__| |__|__| |__|__| Sex.

2 |__|Male |__|Female Years of education: ___ yrsEmployer Name: _____ Which of the below list best describes your current employer? |__| 1. Fire Department Garage |__| 3. Manuf. Dealer or Service |__| 5. Military|__| 7. Independent Service Center |__| 9. Other|__| 2. Municipal Garage |__| 4. Fleet Service Shop|__| 6. Manufacturer |__| 8. Volunteer FD or Rescue ServiceDATE OF EXAM: _____ 21 Day Advance Registration Required for mail or fax, 16 days for SITE # _____ CITY :_____ STATE: _____ see list of test dates and test sitesBlacken the square for exam a maximum of 2 regular exams or 6 re- Certification exams or a combo of 1 reg & 3 recerts may be taken. *Note: Re- Certification exams are for technicians whose Certification is expiring.

3 Regular Re- Certification * $ $ Apparatus ExamsF1 |__||__|F1 Maintenance, Inspection, & Testing F2|__||__|F2 Design & PerformanceF3|__||__|F3 Fire Pumps & AccessoriesF4|__||__|F4 Electrical SystemsFA4 |__| |__|FA4 Advanced Electrical Systems to take the FA-4 you must have F4 or E2F5|__||__|F5 Aerial Fire ApparatusF6|__||__|F6 Allison Automatic TransmissionF7|__||__|F7 Foam SystemsF8|__| |__|F8 Hydraulic SystemsGL|__| |__|GLGround Ladder TestingDO1|__| DO1 Driver Operator Inspection Ambulance ExamsE0|__||__|E0 Maintenance, Inspection & TestingE1|__||__|E1 Design & PerformanceE2|__||__|E2 Electrical SystemsE3|__||__|E3 HVACE4|__||__|E4 Cab, Chassis & PowertrainAirport Rescue & Firefighting Vehicle ExamsA1|__||__|A1 Design & PerformanceA2|__||__|A2 Chassis & ComponentsA3|__||__|A3 Extinguishment SystemsL1|__| |__|L1 Law Enforcement Vehicle InstallationM1|__| |__|M1 Management Level I SupervisorM2|__||__|M2 Management Level II Supervisor to take the M2 you must be certified in M1 June 22, 2017 EVT Certification reserves the right to affirm to interested parties the areas inwhich a technician is EVT s Signature: _____ Date: _____Fees: Number of:Regular exams :_____ X $ = $_____ Re- Certification exams .

4 _____ X $ = $_____ AMOUNT DUET otal Fees = $_____When paying by check use this form as your invoiceIf you provide an email address, you will receive a Confirmation Letter andReference/Objective list within three business days. If not, you will receive it bymail within two weeks. You must have the confirmation letter to be admitted to theexam, along with PICTURE ON-LINE at of Payment: |__| Credit/Debit Card |__| Money Order |__|CheckCredit Card # |__|__|__|__|-|__|__|__|__|-|__|__|__|__ |-|__|__|__|__| Security Code |__|__|__| Expiration Date |__|__|__|__|_____Name on Credit Card- if different from test taker s name_____Billing address-if different Signature of cardholder:_____Email for transaction receipt:_____ _____Mail or fax this form and payment to: EVT Certification commission Inc PO Box 894 Dundee, IL 60118 Phone: 847-426-4075 FAX: 847- 426-4076