Application for Special Medical Gas Business Registration Installer Certification

Transcription

1 Application for Special Medical Gas Business Registration Installer Certification Department of Consumer & Business Services Building Codes Division 1535 Edgewater NW, Salem, OR (503) , Fax: (503) , TTY: (503) Web: bcd.oregon.gov Mail application with payment to: Fiscal Services P.O. Box Salem, OR Name: APPLICANT INFORMATION Work phone: Address (Street or P.O. box): Home phone: Building Codes Division requests the use of your Social Security number for internal use only as an identification number for controlling examination records. SSN: - - DEPARTMENT USE ONLY Approved Signature: Date: Denied Signature: Date: Incomplete Signature: Date: Comments: TYPE OF APPLICATION Application fee: $50 for each category. Application fees are not refundable. Special Medical Gas Business Registration /1001 Special Medical Gas Installer Certification /1001 Fee(s) paid: Send check or money order payable to Department of Consumer and Business Services. If paying by credit card, applicant must sign and date credit card information box. Do not send cash. Visa MasterCard Discover ( ) Credit card number / Expiration date Both the application and verification forms must be completed. The verification form must be signed by the verifier and applicant. (Turn page for complete instructions.) FISCAL USE ONLY Name of cardholder as shown on credit card Cardholder signature Amount $ Page 1

2 INSTRUCTIONS ES: 1. Complete the application form, Page 1. Be sure to check the box Special Medical Gas Business Registration under TYPE OF APPLICATION. 2. Have your business' Oregon-certified public accountant complete the Medical Gas Business Experience Verification, Page 3. This form must be signed and notarized. (To qualify for registration, your company must have completed at least 40 medical gas piping systems or have grossed at least $75,000 installing medical gas systems in Oregon during the two-year period beginning October 23, 1997, and ending October 23, Complete the Business Employment Record, Page 4, listing all employees that have installed medical gas systems for your company. 4. Make the $50 fee (check or money order) payable to the Building Codes Division. If paying by credit card, applicant must sign and date the credit card information box. Mail the application (Page 1) and fee to: Fiscal Services P.O. Box Salem, OR Mail the verification (Pages 3 and 4) to: Building Codes Division INSTALLERS: 1. Complete the application form, Page 1. Be sure to check the box Special Medical Gas Installer Registration under TYPE OF APPLICATION. 3. Complete Medical Gas Installer Experience Verification and Medical Gas Installer Experience, Pages 5 and 6. List all employers for whom you have installed medical gas systems. 4. Make the $50 fee (check or money order) payable to the Building Codes Division. If paying by credit card, applicant must sign and date the credit card information box. Mail the application (Page 1) and fee to: Fiscal Services P.O. Box Salem, OR Mail the verification (Pages 5 and 6) to: Building Codes Division Page 2

3 Medical Gas Business Experience Verification Special Medical Gas Business Registration Department of Consumer & Business Services Building Codes Division 1535 Edgewater NW, Salem, OR (503) , Fax: (503) , TTY: (503) Web: bcd.oregon.gov Mail verification separately to: Building Codes Division VERIFIER / APPLICANT INFORMATION Name of Oregon certified public accountant: Name of medical-gas business owner: DBA: DBA: Notarized verification of qualifications is required for certification with the State of Oregon. Your prompt return of this form to the applicant, filled out as completely as possible, will expedite the disposition of this application. Thank you for your assistance. This application to the Oregon Building Codes Division is for registration as a Special Medical Gas Business VERIFIED EXPERIENCE Describe the kind of buildings, structures, or projects on which the applicant's business has worked. Give any other details that might aid in evaluating the business' experience of installing medical gas systems in Oregon during the two-year period beginning October 23, 1997, and ending October 23, Additional sheets may be attached. I certify that I have personally known the applicant from to and have direct knowledge that the applicant has been operating an Oregon business that has installed more than 40 medical-gas piping systems or grossed more than $75,000 installing medical-gas systems during the two-year period beginning October 23, 1997, and ending October 23, 1999, in Oregon. I certify that the foregoing statements are true and correct. month/year month/year Signature of business owner or representative: Signature of CPA: OR CPA license no.: NOTARY PUBLIC Signed and sworn to before me this day of month/year Notary public: My commission expires: This space is reserved for notarial stamp. Page 3

4 EMPLOYMENT RECORD List your employees involved in the installation of medical-gas piping systems. Describe in detail their related duties and responsibilities, technical areas, the type of buildings and occupancies on which they've worked, etc. If more space is needed to list experience, attach additional sheets. Please print Employee s name: Employee s name: Employee s name: By my signature, I affirm the provided information is true, correct, and complete. I understand that incorrect statements or omission of material facts may result in denial of this application. Business owner signature: Page 4 Date:

5 Medical Gas Installer Experience Verification Special Medical Gas Installer Certification Department of Consumer & Business Services Building Codes Division 1535 Edgewater NW, Salem, OR (503) , Fax: (503) , TTY: (503) Web: bcd.oregon.gov Mail verification separately to: Building Codes Division Name of applicant: INSTALLER VERIFIER / APPLICANT INFORMATION Name of medical gas business owner (verifier): DBA: Notarized verification of qualifications is required for certification with the State of Oregon. Your prompt return of this form to the applicant, filled out as completely as possible, will expedite the disposition of this application. Thank you for your assistance. This application to the Oregon Building Codes Division is for certification as a Special Medical Gas Installer Tell what you know of the applicant's medical-gas installation experience. Give the name of your employee and dates of employment. Describe the kind of buildings, structures, or projects on which the applicant has worked. Give any other details that might aid in evaluatinghis or her experience installing medical-gas systems in Oregon while employed with your company. Additional sheets may be attached. I certify that I have personally known the applicant from to and have direct knowledge the applicant was employed as follows: Position title Duties, skills, functions VERIFIED EXPERIENCE How was knowledge of the above facts acquired? I certify that the foregoing statements are true and correct. Month / year Month / year Period of employment Signature of verifier: A (1/02/COM) NOTARY PUBLIC Signed and sworn to before me this day of Month/year Notary public: My commission expires: Page 5 This space is reserved for notarial stamp.

6 INSTALLER MEDICAL - GAS EXPERIENCE List your experience beginning with your present or most recent position. Describe in detail your related duties and responsibilities, technical areas, the type of buildings and occupancies on which you worked, etc. If more space is needed to list experience, attach additional sheets. Verification of work experience must accompany this application. See attached instructions. Self-verification is not acceptable. Please print Employer s name: Employer s name: Employer s name: RELATED CERTIFICATIONS List current/active medical-gas installer certifications or registrations that meet ASSE standards: Type: No.: Expires: Type: No.: Expires: Type: No.: Expires: A person is not qualified to be licensed if false information is provided in an application. Persons denied licensing under OAR (6) will be required to wait one year from the date the application was denied before they may reapply for any certification. By my signature, I affirm the provided information is true, correct, and complete. I understand that incorrect statements or omission of material facts may result in denial of this application. Applicant signature: Date: A (1/02/COM) Page 6