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Practical Examiner - Application

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

Instructions

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

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:
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:

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 Practical Examiner.
Licenses Held (including drivers) or certifications to practice a trade or profession.
Type	Licence Number	Granted by (licensing board)

List up to three people who you would like to use as a reference.
Full Name	Address	Phone Number	Relationship

Geographic Preference: Indicate cities/states where you would like to work:
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. ___Yes ___No
Prior Convictions.
Have you ever been convicted of any violation of law, including moving traffic violations: ___Yes ___No   If yes, then please provide the following:
Date of Conviction: mm/yy	Describe the Offense:
Date of Conviction: mm/yy	Describe the Offense:
Date of Conviction: mm/yy	Describe the Offense:

When would you like to take the Practical Examiner Training? mm/dd/yy (check www.CraneInstituteCertification.com/pe_training.php or call Wendy Follmer at 763-476-4242 for available dates)

Available Start Date: When will you be available to start giving exams? mm/dd/yy

Do you wish to be listed as a Practical Examiner available to all Exam Sites on the CIC web site (see List Your Services on CIC)?     ___Yes  ___No

 

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 Practical Examiner.   I certify that I am able to fulfill the Responsibilities of a CIC Practical Examiner.   In connection with my application to become a Crane Institute Certification (CIC) Authorized Practical 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:

 

Payment

Please include a check payable to 4ROI for $695 with your application to cover the following services. 4 hours of on-line or classroom training 2 days onsite training, training site, crane, and training materials Initial site support with individual follow-up Application processing Examiner test and scoring, letter and certification card Ongoing customer service Any travel requested of trainer would be paid separately at cost to training provider.

Please mail your application and check made payable to 4ROI to:

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