Practical Exam Site - Application

This application consists of four parts: Site Information, Exam Dates, Practical Exam Site Security Agreement, and Payment.

All fields on the form must be completed. Incomplete forms may delay activation. The Exam Site Coordinator will be notified by email when your exam site has been activated. Allow at least two (2) weeks for an exam site to be approved and activated on the CIC registration system.

Instructions

1. Print full application.
2. Complete all four sections of the application. Please print clearly.
3. Mail the application and payment to the address noted below the application.

Site Information

Company Name:
Exam Site Street Address 1:
Exam Site Street Address 2:
City: State: Zip:
Company Mailing Address 1:
(for receipt of any materials, if different than above)
Company Mailing Address 2:
City: State: Zip:
Number of candidates you expect to test annually: Number of candidates this Exam Site can test simultaneously:
Make this exam site open to candidates outside your company?
(see List Site on CIC)
Check One
 
Yes
 
 
No
Does the Exam Site meet the size
requirements?
Check One
 
Yes
 
 
No
Exam Site Business Hours
(Check all days and times that exams are offered):
 
 
Monday		 From ___:___  To  ___:___
 
Tuesday		 From ___:___  To  ___:___
 
Wednesday		 From ___:___  To  ___:___
 
Thursday		 From ___:___  To  ___:___
 
Friday		 From ___:___  To  ___:___
 
Saturday		 From ___:___  To  ___:___
 
Sunday		 From ___:___  To  ___:___

Site Information (continued)

Exam types this site plans to administer
(Check all that apply):
 
 
Telescoping Boom – Under 21 tons
 
Telescoping Boom – 21 - 75 tons
 
Telescoping Boom – Over 75 tons
 
Lattice Boom – Carrier
 
Lattice Boom – Crawler
Practical Exam Site Coordinator must initial each of the following
 
_______ I have read and understand the Practical Exam Site Requirements
 
_______ I have read and understand the Practical Exam Site Coordinator Responsibilities
 

If unable to meet any Practical Exam Site Requirements, please explain: 


 
 
 

Exam Dates

What date(s) would this site offer exams in the next year. You will be able to delete these dates or add new ones after the site has been approved. (Use mm-dd-yy format.)  

 

  Practical Exam Site Security Agreement

As a responsible party participating in the administration of practical examinations for Crane Institute of America Certification, Inc. hereinafter called CIC, I, the undersigned, accept responsibility for maintaining the strict confidentiality of all examination-related materials.

  1. I accept responsibility for protecting confidential materials and information. I will not discuss any aspect of the examination administration process with anyone except the approved CIC Practical Exam Site Coordinator for our site, CIC Practical Examiners, Proctors, 4ROI and CIC contact persons.
  2. I will not discuss the contents of any examination materials except with the 4ROI or the CIC contact person.
  3. I will read and follow the exam policies and procedures provided in the CIC Practical Site Coordinator Handbook.
  4. I will read the exam site requirements provided in the CIC Practical Exam Site Coordinator Handbook and will ensure those guidelines are followed when preparing the exam site.
  5. I agree to be at the exam site during the entire exam administration process or to arrange for a designated individual to admit authorized personnel.
  6. I agree not to misrepresent or omit any factual information in documentation provided to CIC or 4ROI or to knowingly allow anyone else to make such misrepresentation or omission.

I am aware that violations of these provisions will result in CIC revoking our status as a CIC Practical Exam Site for CIC Examinations and that I could be liable for civil and/or criminal action.

I have read and understand the provisions of this Security Agreement.

My signature below signifies 1) That I agree to the terms of this Security Agreement without reservation, 2) I have read, understand and will maintain the Practical Exam Site Requirements, and 3) I have read, understood, and agree to the Practical Exam Site Coordinator Responsibilities.
Exam Site Coordinator’s Name (Print):
Exam Site Coordinator Signature: Date:
E-mail (required): Fax:
Business Phone: Secondary Phone:
Supervisor’s Name (Print): Supervisor’s Phone:
Supervisor’s Signature: Date:

Payment

Please include a check payable to 4ROI, or fill in all credit card information below, with your application in order for the application to be processed.
Required application processing fee (non-refundable) $195.
CIC sling required to conduct practical exams $285.
Total $480

If you prefer not to purchase the CIC sling at this time, include payment for only $195. Please note that one CIC sling is required to conduct practical exams.

Amount to Charge:  
Card Type:  
Card Number:  
Expiration Date:  
Signature:  

Please submit your application with completed credit card information, or check payable to 4ROI, by mail to:

4ROI
One Carlson Parkway, Suite 230
Minneapolis, MN 55447
Attn: CIC Exam Site Request Application