CF024 Recertification Form V7 2015-1-23 - Fillable PDF

Renewal of Vibration Analyst Certification
Application Form
IMPORTANT INFORMATION: READ CAREFULLY BEFORE PROCEEDING
Make sure you are using the latest version of the Renewal Application. Applications received on obsolete
versions of the Application will be returned. The latest version can be downloaded on the Vibration Institute
website at http://www.vi-institute.org/recertification.
Responsibility: It is the applicant’s responsibility to read, understand, and follow all instructions given in this
application. It is also your responsibility to submit this form on time in order to be considered for renewal by
points. If you have any questions, contact the Vibration Institute at 630.654.2254 or email VICertification@vi-
institute.org.
Application Fee: Effective January 1, 2015, there is a $250 fee ($300 International) for processing this renewal
application, payable upon submittal of the application. This fee also covers the issue of a new 5-year certificate if
approved. If your application is denied, you may apply 50% of the application fee toward an exam fee, if the
exam is taken within one calendar year of the expiration of your current certification. Your application fee may
be reduced if you participated in the Vibration Institute’s optional Proactive Surveillance Program (PSP) over the
past five years. Contact the Vibration Institute for details. Note: Due to changes in ISO/IEC 17024:2012, the
Vibration Institute’s optional PSP program has been discontinued.
Recertification Fee: Prior to January 1, 2015, an applicant will be charged a fee for renewal of their certification
when it is approved. The fee is based on whether or not this is the first renewal of the certificate and on prior
participation in the optional PSP program. Contact the Vibration Institute for details.
Qualification: In order to qualify for renewal of your certification by points rather than by re-examination, you
must have continued, uninterrupted, vibration-related work experience and show evidence of ongoing
vibration-related professional development. Note: Qualifying experience and professional development in
companion technologies is limited as described later in this application.
General Information and instructions:
1. Your certification expires on the expiration date shown on your certificate. If this form is not received
and approved prior to that date, you are no longer certified and cannot state so. You have a 6-month
grace period that extends beyond the expiration date to allow late submittal of this application form but
during that timeframe, you are not certified. It is recommended that this form be submitted 3 to 6
months, but no more than 6 months, prior to your certificate expiration date so there is no lapse in your
V.I. Form CF024 Revision: 7, 2015-1-23 Page 1 of 14

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certification. Be sure to check the Vibration Institute website to make sure you have the latest version
of this form; only the latest version of this form will be accepted.
2. If you submit this application form after the 6-month grace period has expired, it will not be considered
and you will be required to retake the certification exam to get recertified.
3. You must meet the renewal criteria as defined in this application in order to be recertified by points. If
you do not meet the criteria, you will be required to retake the certification examination to get
recertified. Note: This is true even if you participated in the Vibration Institute’s optional PSP (Proactive
Surveillance Program).
4. This application must be filled out completely and legibly in order to be considered. All blanks must be
filled in or the form will be returned to you for completion.
5. Please avoid using abbreviations that the reviewer may not be familiar with. This will only delay the
review. Example: Don’t say you took PFB training from TA; instead state you took Practical Field
Balancing from Technical Associates of Charlotte. This will aid in processing the application and avoid
requests for clarifications.
6. Use the correct name of the classes, organizations, conferences, etc. so they can be easily verified.
Example: If you took “Introduction to Machinery Vibrations”, don’t say you took “Basic Vibrations or if
you attended the Turbomachinery Symposium, don’t say Turbo as this makes it difficult to verify and
delays processing of the application.
7. You MUST provide evidence of training, conference attendance, presentations, publications,

etc. (e.g. an attendance certificate) with your application form. See the definition of evidence on
page 4 of this application. Please note that attestation by signature alone is not acceptable as proof of
activities. Our accreditation to ISO/IEC 17024:2012 requires that we verify point claims with evidence
provided by the applicant.
8. If available, please provide a web address (URL) for the class, conference, etc. that is claimed. This will
help the reviewer verify the point credits for the item and facilitate processing of the application.
9. Training, papers, presentations, etc. that are claimed for renewal points must have occurred within the
5-year period in which you were certified. These dates are shown on your Certificate. Items falling
outside of these dates cannot be considered,
10. Training, presentations, published papers, conferences and meetings must not only be from recognized
industry publications and training organizations but also must be verifiable. Other formal and verifiable
supervised training with a defined syllabus, training materials, and competent instructor may be
considered if supplied with supporting documentation as defined in this document.

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11. Professional development points cannot be claimed for work done or reports written on the job.
Additionally, points cannot be claimed for presentations given at staff meetings, internal company
reviews, and other meetings that are part of your normal job requirements. Credit for this work is
included in your experience points.
12. Do not ask the application reviewer to contact a person or organization to verify your claim via email or
phone. It is your responsibility to provide acceptable evidence for your claims. If you submit an
application without proper evidence, it will not be processed pending the submission of the required
evidence.
13. You must sign the “Attestation” at the end of this Form. Falsifying information is a violation of the
“Vibration Institute Code of Ethics” and could result in loss of your Certification. Please review the Code
of Ethics on the Vibration Institute website at: http://vi.membershipsoftware.org/codeofethics.
Definitions, Limitations, and Appeals:

Vibration-Related - The term Vibration-Related is used throughout this document and means professional
development activities that are related to the subjects and topics contained within the Body of Knowledge of
the Vibration Institute’s certification scheme in accordance with ISO 18436-2:2014 and other pertinent
Standards. Points are awarded for experience, training, conference attendance, presentations, published papers
and other approved activities as determined by the Vibration Institute.
Evidence – Evidence is documentation that clearly shows that you participated in a claimed activity. It must
include the date(s) of the qualifying activity, topic, organization providing the activity, and qualifying hours or
CEU’s. Acceptable documentation includes: certificate of attendance, letter from the supplier stating your
participation, log in sheet signed by the attendee and provider, an agenda or program signed by the provider
verifying participation.
A copy of a presentation or paper by itself does not constitute valid evidence. You must include proof of where it
was presented or published, the date, and a way to verify that information, e.g., conference program,
proceedings listing, or publication table of contents.
Participation in local meetings cannot be lumped together. Each meeting attended must be listed with the
required information and supporting evidence must be supplied. In the case of Vibration Institute, CMVA, or
similar regular meetings, a letter from an officer of the local chapter confirming the claims is acceptable.
Companion Technology Limitation - Points are awarded for professional development in companion
technologies, however, they are limited to no more than 50% of the total professional development points
claimed in Section 3A, 3B, & 3C, and may not exceed 6 points total contribution over the five year certification
period at any category. Companion Technologies include but may not be limited to the following.
• Thermography and infrared analysis

• Oil analysis
• Ferrography and wear particle analysis
• Ultrasonic analysis

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• Shaft alignment
• Motor analysis other than vibration (e.g., motor current analysis, hi-pot testing, etc.)
• Reliability Based or Centered Maintenance (RBM or RCM) type training
• Other related technologies
Machinery Knowledge - Since machinery knowledge is included in the Body of Knowledge, formal classes and
training related to machinery operation, maintenance, and repair may be considered as part of vibration-related
rather than a companion technology. If you are claiming such training, you must provide evidence of attendance
and documentation describing the training for consideration by the reviewer.
Appeals and Complaints - Individuals denied renewal may make written appeal to the Certification Committee
or Technical Director of Certification. The appeal form can be obtained at http://www.vi-
institute.org/files/CF021%20COMPLAINT%20OR%20APPEAL%20FORM.pdf. You may also send a complaint to
the Executive Director who will forward it on to the appropriate person. Unsuccessful appeals to the
Certification Committee or Technical Director of Certification can be appealed to the Vibration Institute
Board of Directors in written form. The Board of Directors will provide a decision to grant or deny an appeal
based on the facts. A decision by the Board of Directors is final.
RETURN COMPLETED FORM TO:

Vibration Institute
2625 Butterfield Road, Suite 128N
Oak Brook, IL 60523
Phone: 630-654-2254 | Fax: 630-654-2271
www.vi-institute.org
information@vi-institute.org

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Section 1: General Information
Please provide all of the information requested in this application. Either type the information or print legibly. If
the information is not legible, the Application will be returned to you for clarification. For “Certificate Name”,
include your name exactly as you would like it to appear on your Certificate. If you are outside the United
States, fill in address information as is appropriate for your country. Include your certification number not your
membership number. If you are not sure what your certification number is, contact the Vibration Institute prior
to submitting this application. Note: Cert is used as an abbreviation for Certification.
Jeffrey R. Marrs
Name ___________________________________________________________________________
Jeffrey R. Marrs
Certificate Name __________________________________________________________________
III Cert Number _________________
Cert Category ______ 6/30/2015
9506-0186B Cert Expiration Date: _______________
NextEra Energy - Seabrook Station
Company ________________________________________________________________________
PO Box 300
Address _________________________________________________________________________
Seabrook / NH / 03874
City/State/Zip ____________________________________________________________________
USA
Country _________________________________________________________________________
Jeffrey.Marrs@FPL.com
Email: ___________________________________________________________________________

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Points Required for Recertification
Recertification points are earned for both work experience and professional development. The list below
designates, by certification category, the number of total points required for renewal of certification by
Category. You cannot receive enough points for renewal by simply working full time in vibration analysis; you
must also have ongoing professional development. Please note that no more than 1-point per year in work
experience (Section 2) and no more than 50% of your professional development points or 6 points whichever
is lower (Section 3) can be earned in companion technologies (i.e., thermography, oil analysis, etc.). The rest
of the points must come from verifiable professional development in qualifying vibration-related activities.
Based on the criteria stated above, the absolute maximum number of points that can be claimed for work
experience plus professional development in companion technologies is as follows: Category I = 7, Category II =
9, and Category III and IV = 11.
Total Points Required for Recertification by Category

Category I 24 points
Category II 28 points
Category III 32 Points
Category IV 36 Points
Total Point Summary (from following Sections) Points

Section 2 Work Experience __________
20
Section 3A Documented Technical Training __________
8
Section 3B Technical Meetings and Conference Attendance __________
2
Section 3C Technical Presentations and Publications __________
2
Total Points (Add points from Sections 2, 3A, 3B, & 3C) __________
32

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Section 2. Work Experience
Points are earned by performing vibration-related work on an ongoing basis. The rates per year at which points
are earned are shown below. The percentage of time engaged in vibration-related work is based on a standard
2,080 hour work year. Note: Not more than 1-point per year can be claimed for work experience in companion
technologies. Companion technology points claimed under work experience are counted in addition to the
points that can be claimed in companion technologies for professional development in Section 3.
Renewal of certification by points requires that the certificant has been engaged in vibration-related work
without any significant interruption. Significant interruption is defined in Section 3.6 of ISO 18436-1:2012 as
follows: “absence or change of activity which prevents the certified individual from practicing the duties
corresponding to the category in the method and the sector(s) within the certified scope, for either a continuous
period in excess of one year or two or more periods for a total time exceeding two years.” Thus, the minimum
number of vibration-related work experience points required for renewal for each year is one (1). If you had a
year where you did not engage in any vibration-related work, you do not qualify for renewal by points and you
will be required to retake the certification exam to get recertified.
The maximum number of work experience points in any given year is 4 and the maximum for 5-years is 20.
Please note that in Section 4 you are personally attesting to the validity of this information and that falsifying
information could result in the loss of your certification. For more details, please contact the Vibration Institute.
Experience Points Rates
0% 0 points
>10% 1 point
>20% 2 points
>40% 3 points
>60% 4 points
In the Experience Table below, fill in the percentage of time you worked in vibration-related and the percentage
of time you worked in companion technologies for each year. No more than 1-point can be claimed for
companion technologies for any year regardless of the percentage of time spent in those activities. Thus, you
must have spent at least 40% of your time in vibration-related work in order to qualify for 4-points for the year.
Stated another way, in order to claim 4-points in any year, you must either spend at least 60% of your time in
vibration-related work or spend 40% in vibration-related plus an additional 20% in companion technologies
work.
Your current supervisor must sign and attest to the work experience claims made below. If they have not been
your supervisor for the full 5-year period, they can attest to the best of their knowledge. If you are self-
employed, such as an independent consultant, you can either have a colleague sign or sign yourself. Please note
that falsifying information could lead to loss of your Certification. An electronic signature may be used or, you
may have your supervisor send an email to vicertification@vi-institute.org attesting to the information. If an
email is sent, you must have them clearly state who the attestation is for.

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Experience Table
Year % Vibration % Companion Points

Related Technologies
__________
2011 ____________
50 ____________
50 ____________
4
__________
2012 ____________
50 ____________
50 ____________
4
__________
2013 ____________
50 ____________
50 ____________
4
__________
2014 ____________
50 ____________
50 ____________
4
__________
2015 ____________
50 ____________
50 ____________
4
Vibration-Related Experience: (please check all that apply)
□ acceptance testing □ condition evaluation □ data collection

□ diagnostic testing □ engineering □ program setup
□ program supervision □ vibration analysis □ vibration monitoring
□ other (please specify)
Specify:_______________________________________________________________________________
Machinery Balancing
Give a brief description of your typical job duties:

___________________________________________________________________________________________
I am a Principal Nuclear Engineer at Seabrook Station. I am in the Condition Based Maintenance group as a Program Engineer. I am the Program Owner for
___________________________________________________________________________________________
the Infrared Thermography and Lube Oil Analysis Programs and the back up Program Owner for the Vibration Analysis Program. I perform all field activities for all of the programs.
___________________________________________________________________________________________
This includes all data collection for the Vibration and Infrared programs. I also coordinate the shipping of all of LO samples and review and report on the results.
___________________________________________________________________________________________
The CBM program at Seabrook Station consists of two Principal Engineers collecting all of the data and performing all of the analysis, on-site. I perform all IRT routes
___________________________________________________________________________________________
and perform the analysis in the field as part of the field surveys. We do all of the IRT routes including all of the Motor Control and Switchgear cubicles and the operating equipment.
___________________________________________________________________________________________
Vibration data collection accounts for approximately 50% of my time, the other 50% of my time is spent on the IRT & LO Programs managing the field work and results reporting.
I _______________________________
Robert I Parry (Print Supervisor’s Name) attest that the work experience information
presented above by ___________________________
Jeffrey R. Marrs (Print Applicant’s Name) is accurate to the best of my
knowledge.
Signature of Supervisor: ___________________________________ Date: ____________________
___ Check here if you are self-employed and signing for yourself.
If you simply type in your initials and/or name, they will be interpreted as your signed initials and signature.

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Section 3A. Professional Development - Documented Technical Training
Training – Points for training are awarded for attending formal classes from recognized training organizations.
Other verifiable supervised training with a defined syllabus, training materials, and competent instructor may be
considered, however, evidence of such must be provided with this application for consideration. Points are not
awarded for working with a Certified Vibration Analyst that is providing ongoing mentoring to you. Time spent
taking certification exams does not qualify for points, however, time spent on training exams and structured
reviews that are part of a formal class does qualify. If you claim points for a non-recognized class, you must
present evidence of the class, including, a syllabus, samples of class materials, number of hours of instruction
time, the timeframe over which it was provided (e.g., 24 hours of instruction over 3-days), the dates and
location of the training, and proof of attendance and completion for consideration. Points are not awarded for
non-verifiable, non-supervised, self-study, or independent training such as viewing tapes, CD’s, or YouTube
videos.
Teaching Classes – Points for teaching classes are awarded for teaching formal classes for recognized training
organizations. Points may be awarded for teaching verifiable formal training classes with a defined syllabus and
appropriate training material. Points are not awarded for informal training sessions, informal classes, or
ongoing mentoring. If you claim teaching points and it is not for a recognized training organization and a
published course, you must present evidence of the class, including, a syllabus, samples of class materials,
number of hours of instruction time, the timeframe over which it was provided (e.g., 24 hours of instruction
over 3-days), the dates and location of the training, and the number of class attendees for consideration.
Repeating a Class - Points for attendance or teaching the same class or training are only granted once per year
(i.e., at least 1-year between occurrences). Points awarded for attending or teaching the same class in additional
years are earned at 50% of the stated rates. Example: A 3-day, 8-hour per day class earns 2.4 points. If it is
repeated a year later, it earns 1.2 points.
Fill out the information below for every class claimed.
Class Title, Name, or Topic ______________________________________________________________

Optical Gas Imaging with the FLIR GF Series Camera
URL/Web Address (provide if known) ______________________________________________________
www.infraredtraining.com
Vendor or Person Teaching ______________________________________________________________
Dr. Robert Madding - Infrared Training Center
Date(s) of Training ___________________________
12/6/2011 - 12/8/2011 Evidence Provided? ____
X Yes ____ No
Location of the Training _________________________________________________________________
SHERMCO Cedar Park (Austin), TX
Duration of the Training in Hours __________
24 X 0.1 = __________
2.4 Points

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ADRE 408 DSPi/SxP Training - Getting the Most From ADRE SxP
www.GE-Energy.turnstilesystems.com
John Kingham - GE Bently Nevada
March 13 - 15, 2012 Evidence Provided? ____
X Yes ____ No
Seabrook Station Training Center
24 X 0.1 = __________
2.4 Points

Bently Nevada Day - Users Group Meeting
John Kingham - GE Bently Nevada
6/22/2011 Evidence Provided? ____
X Yes ____ No
Billerica, MA
8 X 0.1 = __________
0.8 Points

Introduction to Modal & ODS Analysis for the Plant Vibration Analyst
www.FSDiagnostics.com
Dan Ambre - Full Spectrum Diagnostics
X Yes ____ No
Seabrook Station - On-site Classroom and Hands-On Training
24 X 0.1 = __________
2.4 Points

Date(s) of Training ___________________________ Evidence Provided? ____ Yes ____ No
Duration of the Training in Hours __________ X 0.1 = __________ Points

Date(s) of Training ___________________________ Evidence Provided? ____ Yes ____ No
Duration of the Training in Hours __________ X 0.1 = __________ Points

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Section 3B. Professional Development - Technical Meeting & Conference Attendance
Technical Meetings and Conferences – Points are awarded for attendance at recognized industry technical
meetings and conferences. If you attend an intra-company or other non-recognized meeting or conference, you
must submit an agenda of topics and presentations for the event, the date(s), indicate what you attended or
participated in, indicate the number of hours of participation, and provide proof of attendance for
consideration.
Teleconferences and Online Meetings - Teleconferences do not qualify for points credit, however, if the
conference was held via WebEx, GoToMeeting or other similar online meeting environment where technical
presentations may be viewed interactively (two-way communication with the presenter, question, answers, etc.)
it may be considered. In general, to get credit for online training or an online conference, it must be from a
recognized training organization. To apply for points for online training and meetings for intra-company or non-
recognized events, you must submit an agenda of topics and presentations for the event, the date(s), indicate
what you participated in, indicate the number of hours of participation, and provide proof of participation for
consideration.
Correspondence Courses – Points for successfully completing formal correspondence courses from recognized
organizations may be claimed. The number of points claimed is generally equal to the number of CEU’s awarded
for the course.
Points are earned at the following rates.

• 0.1 point per hour for VI Chapter, VI Committee, VI Board/Officer, and any verifiable vibration standards
committee meetings. Note: Typical VI Chapter, CMVA, or other similar vibration organization meetings
with a 1-hour presentation can receive 0.2 points since 0.1 point is allowed for networking. (Max 3
pts/yr)
• 3.0 points for full attendance at the following conferences: VI, CMVA, MFPT, ASME, Turbomachinery
and IMAC (Max 6 pts/year) Note: If less than full attendance, then compute points at 0.1 point per hour
of attendance.
• 0.5 points per day for other committee & technical standards meetings (except vibration standard
meetings as described above) and conferences (Max 6 pts/yr)
Fill out the information below for every technical meeting and conference attended.
Title or Name of Event _________________________________________________________________

Inframation 2015 Thermography Conference
URL/Web Address (provide if known) _____________________________________________________
www.infraredtraining.com
Date(s) of Event ____________________________
X Yes, ____ No
Location of Event ______________________________________________________________________
Nashville, TN
Duration of the Event in Hours ______________
32 (4 Days) Points _____________
2.0

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Date(s) of Event ____________________________ Evidence Provided? ____ Yes, ____ No
Duration of the Event in Hours ______________ Points _____________
Title or Name of Event ________________________________________________________________

Location of Event _____________________________________________________________________



Location of Event _____________________________________________________________________


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Section 3C. Professional Development - Technical Presentations & Publications
Points are earned for original, documented vibration-related technical presentations at recognized conferences
and for original, published vibration-related articles/papers in recognized technical publications available for
public distribution. Points are only awarded once for publications and may not be submitted again.
Presentations may be submitted once per five year certification period if it is presented again at a recognized
conference. Points are earned at the following rates: 2.0 points per technical presentation and 3.0 points per
published article. Note: If a paper is published in a recognized publication and the paper is presented at a
recognized conference by you, 5.0 points are allowed.
Fill out the information below for every Technical Presentations & Publications
Title of Presentation/Article _____________________________________________________________

Steam Turbine #1 Main Bearing Failure Detection
Venue or Publication ___________________________________________________________________
Presented during Bently Nevada Day - Users Group Meeting
Date of Presentation or Publication ____________________
6/22/2011 Evidence Provided? X
____ Yes ____ No
Article Published ____
No Presentation Only ____
Yes Paper & Presentation ____
No Points (5 max) 2.0
___________
Date of Presentation or Publication ____________________ Evidence Provided? ____ Yes ____ No
Article Published ____ Presentation Only ____ Paper & Presentation ____ Points (5 max)
___________
___________
___________
If you require more room for Sections 3A, 3B, or 3C, please add a separate sheet providing the same details
for additional training, meetings, conferences, presentations, and/or publications.

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Section 4: Attestation
In order to qualify for renewal of certification by points, you must meet and attest to each the following
statements. Read the statements carefully and initial, then sign at the bottom. You may use an electronic
signature. If you simply type in your initials and/or signature, it will be interpreted as your signed initials and
signature.
Jeffrey R. Marrs
I _____________________________________ (your name) attest to each of the following statements.
JRM
__________ I have actively worked in the field of vibration analysis without significant interruption since
receiving my vibration analyst certification. See the definition of significant interruption in Section 2.
JRM
__________ I have participated in the professional development activities as stated in Section 3 of this renewal
application since receiving my last certification.
JRM
__________ I have and continue to follow the Vibration Institute Code of Ethics that includes the Code of Ethics
as stated in Annex A of ISO 18436-1:2012.
JRM
__________ The information provided in this application is true, accurate, and complete to the best of my
knowledge. Additionally, I am willing to provide in a timely manner, any additional evidence requested by the
Vibration Institute that supports the information provided in this form. I understand that falsifying information
could result in the loss of my Certification.
Jeffrey R. Marrs
Print Name: _________________________________________
Digitally signed by jeffrey_marrs@fpl.com
jeffrey_marrs@fpl.com DN: cn=jeffrey_marrs@fpl.com
Signature: ___________________________________________
Date: 2015.09.14 14:44:15 -04'00' 9/14/2015
Date Signed: _____________
Vibration Institute Use Only
Experience Points Allowed __________

Documented Training Points Allowed __________
Meeting and Conference Attendance Points Allowed __________
Presentations & Publications Points Allowed __________
Total Points Allowed __________
Approved ____ Not Approved _____ Date: ________________
By _________________________________________________ Recert. Fee Received:
Title: _______________________________________________ Date______ Amount _____

CP014

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Renewal of Vibration Analyst Certification

IMPORTANT INFORMATION: READ CAREFULLY BEFORE PROCEEDING

General Information and instructions:

V.I. Form CF024 Revision: 7, 2015-1-23 Page 1 of 14

7. You MUST provide evidence of training, conference attendance, presentations, publications,

V.I. Form CF024 Revision: 7, 2015-1-23 Page 2 of 14

Definitions, Limitations, and Appeals:

• Thermography and infrared analysis

V.I. Form CF024 Revision: 7, 2015-1-23 Page 3 of 14

RETURN COMPLETED FORM TO:

V.I. Form CF024 Revision: 7, 2015-1-23 Page 4 of 14

V.I. Form CF024 Revision: 7, 2015-1-23 Page 5 of 14

Total Points Required for Recertification by Category

Total Point Summary (from following Sections) Points

V.I. Form CF024 Revision: 7, 2015-1-23 Page 6 of 14

Experience Points Rates

V.I. Form CF024 Revision: 7, 2015-1-23 Page 7 of 14

Year % Vibration % Companion Points

Vibration-Related Experience: (please check all that apply)

□ acceptance testing □ condition evaluation □ data collection

Give a brief description of your typical job duties:

Signature of Supervisor: ___________________________________ Date: ____________________

V.I. Form CF024 Revision: 7, 2015-1-23 Page 8 of 14

Fill out the information below for every class claimed.

Class Title, Name, or Topic ______________________________________________________________

V.I. Form CF024 Revision: 7, 2015-1-23 Page 9 of 14

Class Title, Name, or Topic ______________________________________________________________

Class Title, Name, or Topic ______________________________________________________________

Class Title, Name, or Topic ______________________________________________________________

Class Title, Name, or Topic ______________________________________________________________

V.I. Form CF024 Revision: 7, 2015-1-23 Page 10 of 14

Points are earned at the following rates.

Title or Name of Event _________________________________________________________________

V.I. Form CF024 Revision: 7, 2015-1-23 Page 11 of 14

Title or Name of Event ________________________________________________________________

Title or Name of Event _________________________________________________________________

Title or Name of Event _________________________________________________________________

Title or Name of Event _________________________________________________________________

Title or Name of Event _________________________________________________________________

V.I. Form CF024 Revision: 7, 2015-1-23 Page 12 of 14

Title of Presentation/Article _____________________________________________________________

V.I. Form CF024 Revision: 7, 2015-1-23 Page 13 of 14

Vibration Institute Use Only

Experience Points Allowed __________

Approved ____ Not Approved _____ Date: ________________

By _________________________________________________ Recert. Fee Received:

Title: _______________________________________________ Date______ Amount _____

V.I. Form CF024 Revision: 7, 2015-1-23 Page 14 of 14

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Signature of Supervisor: _______________ Date:

Approved __ Not Approved _ Date: ______________

Title: _________________________________________ Date Amount _