EVT Certification Commission, Inc. Exam …

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.

2 |__|__|__|__|__|__|__|__|__|__|__|__|__| __|__|__|__|__|__|__|__|__|__|__|__|__|_ _|__|__|Date of Birth |__|__| |__|__| |__|__| Sex: |__|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.

3 *Note: Re- Certification exams are for technicians whose Certification is expiring. 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.

4 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 :_____ 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.

5 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