Written Examiner - Application

You must submit this application in order to verify your eligibility to be trained as a Chief Written Examiner to administer Crane Institute Certification (CIC) written exams. This application consists of Background Information, a Release to allow us to verify the information on your application, and a security agreement.

Instructions

1. Print full application.
2. Complete all fields in the application. Please print clearly.
3. Mail the completed application to the address at the bottom of the page.

Background Information

In connection with your application to become authorized as a CIC Chief Written Examiner, all information on the application is subject to verification. You will need to agree that CIC may contact references and educational institutions listed on your application and consent to a background check. 

Print your full legal name.
Last: First: Middle:
List additional names you have been employed or enrolled under.
Last: First: Middle:
Last: First: Middle:
Social Security #:
Home Phone: Business Phone:
Current Email: Date of Birth (mm/dd/yy):
List your residential addresses for the past seven years:
Street Address 1 (current address):
City: State: Zip:
Street Address 2:
City: State: Zip:
Street Address 3:
City: State: Zip:
Street Address 4:
City: State: Zip:
Street Address 5:
City: State: Zip:
Signature: Date:

Education
Name & Location of Educational Institutions attended, starting with most recent. Degree Received Major / Specialty Dates Attended
       
       
       
Relevant Work Experience: Please list your work experience for the past five years beginning with the most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Job Title: Job Duties:
From: (mm/yy)                  To: (mm/yy) Reason for Leaving:
Company Name:
Street Address 1:
City: State: Zip:
Supervisor Name: Phone:
 
Job Title: Job Duties:
From: (mm/yy)                  To: (mm/yy) Reason for Leaving:
Company Name:
Street Address 1:
City: State: Zip:
Supervisor Name: Phone:
 
Job Title: Job Duties:
From: (mm/yy)                  To: (mm/yy) Reason for Leaving:
Company Name:
Street Address 1:
City: State: Zip:
Supervisor Name: Phone:
Industry Relationships: Do you currently work for:
A crane rental company? (circle one) Yes No
A crane and/or rigging training company? (circle one) Yes No
Any organization related to the crane/rigging industry? (circle one) Yes No
Do you currently have friends or relatives in the crane/rigging industry? (circle one) Yes No
If yes to any of the above, please explain:



Job Skills: Use the following space to provide any additional information that you think would be helpful in our evaluation of your skills to be a Written Examiner.
 
 
 
 
 
 
 
 
Licenses Held (including drivers) or certifications to practice a trade or profession.
Type License Number Granted by (licensing board)
     
     
     
     
     
Professional References: List up to three people who you would like to use as a reference.
Full Name Address Phone Number Relationship
       
       
       
Compliance with the Immigration Reform and Control Act: I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States. (circle one) Yes No
Prior Convictions: During the past 7 years, have you been convicted of a felony? (circle one)

If yes, then please provide the following:		 Yes No
Location:
 
Date of Conviction (mm/yy):
 		 Describe the Offense:
Location:
 
Date of Conviction (mm/yy):
 		 Describe the Offense:
Location:
 
Date of Conviction (mm/yy):
 		 Describe the Offense:

Training Date: When would you like to take the Written Examiner Training? mm/dd/yy
(See Traveling Chief Written Examiner training call Barbara Weedin at 800-832-2726 for available dates.)
Available Start Date: When will you be available to start giving exams? mm/dd/yy
Traveling: Select the distance you are willing to travel to proctor an exam: (circle one) Less than 50 miles 50-100 miles Over 100 miles

Release

I hereby certify that all entries on this job application and any attachments are true and complete. I also agree and understand that any falsification of this information may result in my forfeiture of authorization as a CIC Chief Examiner.
 
I certify that I am able to fulfill the Responsibilities of a CIC Written Examiner.
 
In connection with my application to become a Crane Institute Certification (CIC) Authorized Chief Written Examiner, I understand that all information on the application is subject to verification. I agree that you may contact references and educational institutions listed on my application. I also consent to a background check.
Print your full legal name (Last Name, First Name, Middle):
Signature: Date:

Certification Exam Confidentiality Agreement

In any capacity that I work with Crane Institute of America Certification (CIC) (i.e., Practical Examiner, Proctor, Chief Examiner, Site Coordinator, Governing Committee (i.e. Board of Commissioners), Advisory Board, consultant or member of a work team or subcommittee) I, the undersigned, accept responsibility for maintaining the strict confidentiality and custodianship of all Crane Institute Certification (CIC) examination-related materials.

Examination related material, existing or in development, must be kept secure throughout its preparation, review, administration, and scoring. By signing this form, I am agreeing to assume personal responsibility for keeping this material in a secured location at all times from when I receive the CIC exam materials until they are returned to CIC. The specific examination security standards with which I will comply are:

  1. Keep all exam material secure until returned to CIC
  2. I will ensure that no person copies any exam materials in any format without express written consent of the acting CIC Executive Director
  3. Return all exam material, including any rough drafts, to CIC. Do not retain or copy any exam material for my own files.
  4. Discuss this exam only during formal exam development or review meetings. Topics that may not be discussed with others include, but are not limited to, exam items and responses, scoring standards, the identities and performances of examinees, exam results, and your evaluation of the exam.
  5. I will only administer exams in situations in which:
    • I do not have a working or personal relationship with any of the test candidates
    • I am not employed as a contractor, 1099 or W2 employee of the organization having employees tested
    • I am not an association member or union member of the organization testing members
  6. For three years from your last contact with CIC exam related material, avoid involvement in any exam-oriented review program for prospective examinees of this licensing agency.  Prohibited activities include but are not limited to sharing any confidential information about CIC questions or methods during the design and development or finished product stages.

If you are found to have violated this security agreement, you will be liable for civil action.

As a Chief Written Examiner I further agree that I will be objective and independent of the candidate taking the exams. To insure independence I agree to NOT conduct an exam for any person I knew prior to exam registration or for whom I have an interest in the outcome of their exam. In addition, I will notify CIC immediately upon realizing that I do not meet the requirements for independence.

I have read and understand the provisions of this Security Agreement. My signature below signifies that I agree to the terms of this agreement.
Print your full legal name (Last Name, First Name, Middle):
Signature: Date:

CIC requires a photo of your full face (passport-type photo, no hats, sunglasses, etc.) for your Chief Written Examiner card. Please make the sure you will be recognized by the photo sent. You can:

Please submit your application by mail, fax, or e-mail to:

CIC
One Carlson Parkway
Suite 230
Minneapolis, MN 55447
Attn: CIC Examiner Application Request

Fax: 763-476-4765
E-Mail: Help@CICert.com