DESAI INDUSTRIAL INSPECTION SERVICES

APPLICATION FORM FOR NDT LEVEL I / II/CWI CERTIFICATION

For office use only

ID No. : ______________ Total Fees : ____________________ AFFIX YOUR

Centre : ______________
Fees Received : ____________________ RECENT
By [] Cheque [] DD [] Cash PASSPORT SIZE
Date Received : ____________________ PHOTOGRAPH
Cheque No. / DD No. : _____________
Drawee Bank : ____________________

1.0 Personal Data ( Block letters )

1.1 Name : ____________________________________________________________
Birth Date : _________________ Designation : _________________________
Total Experience : _______ Years _______ Months
Edu. Qualification : Check ONE only which describe your final Edu. Qualification
[] S.S.C. [] H.S.C. [] B.Sc. [] M. Sc. [] D. E. [] B. E. [] M.E. []Other

1.2 Company Name : ____________________________________________________________

Company Address : ____________________________________________________________
____________________________________________________________
____________________________________________________________
City State Country Postal Code
Company Tel . No. : __________________________ Fax : _________________________
E - Mail Address : ____________________________________________________________
1.3 Present Address : ____________________________________________________________
____________________________________________________________
____________________________________________________________
City State Country Postal Code
Residence Tel . No. : __________________________ Fax : _________________________
1.4 Permanent Address : ____________________________________________________________
____________________________________________________________
____________________________________________________________
City State Country Postal Code
Residence Tel . No. : __________________________ Fax : _________________________

2.0 Send mail regarding certification to : [] Company Address [] Present Address [] Permanent Address
It is your responsibility to notify DIIS of address changes.
3.0 Applicant Classification : [] First time applicant
Check which best describes [] Retaking failed examination (s)
your application [] Adding method (s) to previous certification
[] Recertifying by examination
[] Recertifying by evidence of continuing satisfactory performance

For office use only

Course Enroll.
No. No.
_______ ____
_______ ____
_______ ____
_______ ____
_______ ____

4.0 Check the NDT course (s) / examination (s) below for which you are applying :
[] RT [] Level I [] Level II [] Level II with no time at Level I
[] UT [] Level I [] Level II [] Level II with no time at Level I

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[] PT [] Level I [] Level II [] Level II with no time at Level I
[] MT [] Level I [] Level II [] Level II with no time at Level I
[] VT [] Level I [] Level II [] Level II with no time at Level I
[] CWI [] Level I [] Level II [] Level II with no time at Level I

ID No. : ____________ Name :___________________________

Schedule A
( Photocopy this page as often as necessary to list your training history. )

5.0 Training

5.1 Course # ______

Dates of this course : From _______________ to ________________

Total Time ( Hours ) ________________
Instructor Name : ___________________________________________________________________
Provider Name : ___________________________________________________________________
Provider Address : ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
City State Country Postal Code
Provider Tel . No. : ____________________________ Fax : _________________________
Check methods below for which NDT training was received.
[] RT [] UT [] PT [] MT [] VT [] []

List below any names, certificates, employment records, or other documentation you will be maintaining on
file to support this training.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

5.2 Course # ______

Dates of this course : From _______________ to ________________

Total Time ( Hours ) ________________
Instructor Name : ___________________________________________________________________
Provider Name : ______________________________________________________________________
Provider Address : ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
City State Country Postal Code
Provider Tel . No. : ____________________________ Fax : ________________________
Check methods below for which NDT training was received.
[] RT [] UT [] PT [] MT [] VT [] []

List below any names, certificates, employment records, or other documentation you will be maintaining on
file to support this training.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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ID No. : ____________ Name :___________________________

Schedule B
( Photocopy this page as often as necessary to list your experience history. )
6.0 Experience
6.1 Position # ________
Dates of this position : From _______________ to ________________
Total Time ( Months ) ________________
Employer Name : _____________________________________________________________
Employer Contact Name : _____________________________________________________________
Employer Address : _____________________________________________________________
_____________________________________________________________
City State Country Postal Code
Employer Tel . No. : ____________________________ Fax : _________________________
Check methods below for which NDT job function were performed.
[] RT [] UT [] PT [] MT [] VT [] []

List below any names, certificates, employment records, or other documentation you will be maintaining on
file to support the experience claimed.
____________________________________________________________________________________
____________________________________________________________________________________

6.2 To what type of product does / did your job relate ( i.e. buildings, bridges, pipelines, power plants,
shipping, etc.. ) ? _______________________________________________________________
____________________________________________________________________________________

6.3 Duties & Responsibilities

Check the box (es) below which describe your main duty(ies) :

1. Preparing for NDT [] RT [] UT [] PT [] MT [] VT []

2. Communicating NDT instructions [] RT [] UT [] PT [] MT [] VT []
3. Carrying out NDT [] RT [] UT [] PT [] MT [] VT []
4. Supervising NDT activities [] RT [] UT [] PT [] MT [] VT []
5. Developing NDT reports [] RT [] UT [] PT [] MT [] VT []
6. Reviewing NDT reports or data [] RT [] UT [] PT [] MT [] VT []
7. Writing NDT procedures [] RT [] UT [] PT [] MT [] VT []
8. Surveying or monitoring NDT activities [] RT [] UT [] PT [] MT [] VT []
9. Maintaining NDT records [] RT [] UT [] PT [] MT [] VT []
10. Post NDT cleanup [] RT [] UT [] PT [] MT [] VT []
11. Others_____________________________________________________________________________
____________________________________________________________________________
6.4 What percentage of your time did you devote to the duty(ies) indicated above ? ________%
6.5 Fabrication Code. Circle the code(s), standard(s), and/or specification(s) which governed fabrication.
Note : For company /customer specs, circle the code which served as the basis. For other codes, circle
the American equivalent.
ASME : Sec. I Sec. III Sec. V Sec. VIII Sec. IX
B31.1 B31.2 B31.3 B31.4
AWS : D1.1 D1.2 D1.3 D1.4
API : 620 650 5L 1104

EMPLOYMENT VERIFICATION
7.0
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EMPLOYMENT VERIFICATION - To be completed by your supervisor or personnel
manager of your MOST RECENT EMPLOYMENT.

IMPORTANT ! Your application cannot be processed without completion of this form.

Mail this form with your application, do not send separately.

IF SELF EMPLOYED : Do not use this form if self employed. Instead, provide a reference
letter from one of your clients.

Company name : ______________________________________________

Dept./Division : ______________________________________________
Company Address : ______________________________________________
______________________________________________
______________________________________________
City State Country Postal Code
Company Telephone Number : ______________________ Fax : ___________________

I verify that __________________________________________________, is / was

employed by this company and does / did carry out the described principal duties during the
employment period (s) indicated on this application.

My Name is _______________________ My job title is _______________________

Date ____________ Signature _______________________

VISUAL ACUITY RECORD

8.0
Applicant is required to pass an eye examination, with or without corrective lenses to prove (1) near vision
acuity on Jaeger, or equivalent, at 12 inches, and (2) far vision acuity at 20/40, or better. In addition, the
Applicant shall take a color perception test for red / green and blue / yellow differentiation.

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The eye examination must be administered by an Optometrist, Medical Doctor, Registered Nurses, or Certified
Physician’s Assistant no more than 7 months prior to the date of NDT Level I / II examination or
recertification.

 DO NOT ALTER THE PRINTED TEST REQUIREMENTS. DO NOT ADD ANY

MEDICAL TERMINOLOGY. CHECK ONLY ONE BOX PER TEST.

NOTE : Visual acuity records which do not comply with the above will not be accepted.

_____________________________ _________________
Applicant’s name ID . No. (if allotted )

TESTS. Meets without Meets with

eye correction eye correction Does not meet
1. Near Distance Vision
[] Jaeger # 1
[] Jaeger # 2
at a distance of not less than
12 in.(30.5cm) [] [] []

2. Color Vision Meets Does not meet

For Testing used
[] Ishihara Eye Chart
[] Pseudo-Isochromatic plates
[] others, please describe.

2.1 Red / green differentiation [] []

2.2 Blue / yellow differentiation [] []
2.3 others, please describe. _____________________________

I certify that I, _________________________________________________ , administered an eye exam

Name of Eye Examiner
to ______________________________ , on ___________________ which demonstrated the vision
Name of Applicant Mo./ Day / Year
capabilities indicated above. Check one of the following :

[] Optometrist [] Medical Doctor

[] Registered Nurse [] Certified Physician’s Assistant

State License # ________________________ Professional Address : _________________________

_________________________
_________________________
________________________ Telephone No. : _________________________
Signature of Eye examiner

9.0 STATEMENTS AND SIGNATURE

By my signature on this page if certified by DIIS, I understand and agree to abide by the respective
certification level Code of Ethics for Level I / Level II NDT Personnel Certified by KIEL so long as I maintain
a Certificate. Further, I understand the right of KIEL to suspend or revoke any Certificate granted if I abuse
the privileges therein granted to me.

I understand that certifications which may result from this application do not constitute any form of license.

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I hereby attest that facts on this application are true and correct and no information which might be detrimental
to the granting of certification has been withheld. KIEL has the right to request documentation of education,
training, and experience I have listed on this application. I understand that it is my responsibility to maintain
documentation of education, training, and experience required for certification as represented in this
application. If requested, I will supply documentation to KIEL as directed and KIEL has the right to suspend
or revoke my certification pending investigation should I fail to produce the documentation of my claims.
KIEL may make any inquiries necessary to determine my qualifications for certification based upon the
information I have supplied in this application.

I agree to abide by the decision of KIEL relative to the granting and maintenance of any Certifications as
applied for herein.

For valuable consideration, the undersigned, having made application for Personnel Certification before KIEL,
does hereby release and forever discharge KIEL from any and all liabilities, claims, demands, or causes of
action whatsoever, which now exist or which may hereafter arise on account of the undersigned’s activities
henceforth as Personnel Certified by KIEL. The undersigned applicant further acknowledges that this release is
being given as a prerequisite for having filed application for consideration by KIEL.

_______________________________________
Name of Applicant

_______________________________________
Signature of Applicant

__________________________________
Date

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